English - the European Oncology Nursing Society

electronic databases for literature retrieval, access virtual learningenvironments for links to additional learning material, and use mobiledevices, all contribute to the acquisition of transferable skills for caredelivery. Moreover, this enables students on graduation to functionmore effectively when faced with change like new informationsystems or technology in the workplace.Over the last twenty years the use of learning outcomes, as part ofan overall outcomes based approach used in education, has becomecommon in the USA, UK, Ireland, Australia, New Zealand and SouthAfrica. The Bologna process has created considerable interest andindeed movement towards adoption of a learning outcomes basedprocesses for programme design in Europe. This whole systemapproach makes integration of academic and vocational educationand training easier. It also aids the development and introductionof accreditation of prior learning, credit transfer and accumulationand lifelong learning frameworks. At an institutional level learningoutcomes can be expressed at programme and, or module level andcan be used to frame individual units of study such as a lecture ordirected learning activity. Learning outcomes also allow comparisonacross programmes and have the potential to act as an enabler fortransparent European harmonisation (Cowan et al 2005, Mallaberand Turner 2006). In parallel competency frameworks have beendeveloped to differentiate between different grades and expectationsof staff and better conceptualisation of current and future workforcerequirements. Examples of cancer nursing competency frameworksare available via the world wide web (eg. Weatherall 2004, TheNational Cancer Nursing Education Project [EdCAN] 2008) or forspecific competencies (see Consensus Panel on Genetic/GenomicNursing Competencies 2006; Skills for Health 2008)Competency and competenciesFor a profession such as nursing the main aim of any programmeof preparation for initial or specialist practice is that the learneracquires the necessary skills, knowledge and attitudes to practice;in effect that are competent. Establishing a definition of what ismeant by competency or indeed judging that an individual has metthe benchmark of competence is a challenge at best and one fraughtwith controversy (Watson et al 2002). Gonzci (1994) suggests thatthere are a number of ways of viewing of competency. One approachis to focus solely on the behaviour demonstrated by the individual, asecond is to consider the general characteristics demonstrated by anindividual that constitute effective performance; and the third is bydetermining the components that constitute the requirements for therole (competencies) that collectively will constitute competence. Allthese approaches have their weaknesses. The problem with merelyfocusing on behaviour is that underpinning knowledge is assumed,yet remains invisible, or by default viewed as unnecessary andpossibly undervalued. An attention on general attributes may resultin a practitioner failing to have acquired the specific requirementsof the role. Whereas reducing the art and science of nursing merelyto its component parts may not when reconstituted meet theexpectations of public (Calman 2006), employers, statutory andprofessional regulation (Mallaber and Turner 2006) or indeed theindividual. An even greater challenge is the complexity inherentin the measurement (assessment) of competence (Watson et al2002, Topping et al 2002). Despite these weaknesses competencyframeworks have been adopted in the health care sector as a meansof assessing capability, judging performance and even used as basisfor determining level of remuneration such as the scheme Agenda forChange and Knowledge and Skills Framework adopted in the UK (DH2004; DH 2007).Do learning outcomes and competencies reflect practice?The aim of systems that adopt learning outcomes and/orcompetencies is that they provide assurances about what agraduating student or employee will know and be able to do. In effectcreate confidence that practitioners that are produced are fit forpurpose and practice and meet the requirements of the academicaward. To achieve that aim learning outcomes and competenciesadopt the language of objectivity. This gives the impression thatjudging achievement through the use of such frameworks can bescientific in its precision (Hussy and Smith 2002). Whereas manyforms of assessment are anything but precise particularly whendemonstration of achievement of a learning outcome or competencyin the health sciences requires a complex interplay between thestudents knowledge, skills and attitudes, the assessors abilityto make the judgment, the test or task adequately extracts theevidence and the context is stable to ensure it does not influencethe assessment. In effect the reliability and validity, sensitivity andspecificity have to be assured. This is made even more complexin practice settings where control of the learning environment isdifficult particularly in terms of ensuring consistency. Practiceis essentially messy and indeterminate (Schon 1983). There isconsiderable and growing evidence that a range of factors influencepractice assessment not least the failure of assessors to failstudents (Duffy 2003) and the small tyrannies such as the personalcharacteristics of the learner that can influence outcomes. That saidthe levels of reported errors, adverse incidents and failure to reportsystematic failings in competency of health care practitioners inhealth care (European Commission 2005; Pietro et al 2000) createsa real impetus to establish robust approaches for the preparationand continued professional development of current and futuregenerations of practitioners. Hence the enthusiasm for frameworksEducation and training for health care professionals may preparethem for the role but it remains only an element of the necessarypreparation for expertise. It is now widely acknowledged thateducation alone will not result in expertise and that novicepractitioners require a period of consolidation to realise their skillsand knowledge. Exposure and emersion in practice, acts as a catalystfor the transformation and embedding of learning, and after a periodof time the development of expertise (Benner 1984, Benner et al1996, Topping et al 2002). A feature of practice emersion is thatthe learner gains familiarity with the unique features, and culturalnuances, of the particular specialism. However a particular concernnewsletter fall 2008 -5

for educators is that availability of suitable quality clinical learningplacements are becoming less available and funding for clinicaleducators to support students in practise is often limited if availableat all. Clinical skills laboratories have emerged as an alternative asthey provide a stable learning context to reproduce clinical practiceand assist in skill development. .Repeated execution of a procedure in order to develop and maintaincompetency is a feature of industries such as aviation where errorminimisation is paramount (Armitage and Knapman 2003). Indeedcase volume is often used as a criteria for judging the suitability ofa clinical learning environment in health professional education.Utilising approaches that seek to replicate the real world ofhealthcare are also increasingly used to accelerate familiarity withsituations or typical cases through the use of simulated learning. Theevidence is mounting concerning the benefits of simulation especiallythe impact on the confidence of novice practitioners in practice(Moule et al 2008). Confidence without knowledge or skill would be aconcern but the elegance of simulation is that many of the features ofpractise can be introduced but the focus remains on the learning notjust getting the task done. That said simulation can never replace thebenefits of experiential learning in practise.This aim of this paper was to explore whether frameworks that adoptlearning outcomes or competencies make a difference in practice.The benefits of articulating what a practitioner should know and beable to do seem clear even if the complexity of robust evaluationin the messy real world of health care is elusive. A separate butlinked question is whether the use of instruments, or tools, to assessspecific elements of learning or performance have benefit? Further,when all outcomes (or assessments) are aggregated the resultconstitutes competency of the individual clinician. In response….assuring the reliability and validity of assessment in outcome basededucation so patients, employers, regulatory bodies and the individualpractitioner can be confident of competence remains a challenge buthopefully one that is not insurmountable in the future.ReferencesAdam S (2004) A consideration of the nature, role, application andimplications for European education of employing ’learning outcomes’at the local, national and international levels Scottish Executive ISBN0 7559 1058 3 (available for download from: http://www.scotland.gov.uk/Publications/2004/09/19908/42711 accessed 25/05/08)Armitage G & Knapman H. (2003) Adverse events in drugadministration: a literature review. Journal of Nursing Management 11130-140Benner P (1984) From Novice to Expert Menlo Park. CA: Addison-WesleyBenner P, Tanner C A, Chesla C A (1996) Expertise in nursingpractice New York. NY Springer Publishing CompanyBloom B S (1956) Taxonomy of Educational Objectives: TheClassification of Educational Goals: Handbook 1: Cognitive DomainNew York: LongmanCalman L (2006) Patients’ views of nurses’ competence NurseEducation Today 26 8 719-725Consensus Panel on Genetic/Genomic Nursing Competencies(2006). Essential Nursing Competencies and Curricula Guidelinesfor Genetics and Genomics. Silver Spring, MD: American NursesAssociation.Download from http://www.genome.gov/Pages/Careers/HealthProfessionalEducation/geneticscompetency.pdf (accessed24.08.08)Cowan D T , Norman I J , Coopamah VP (2005) A Project toestablish a skills competency matrix for EU nurses British Journal ofNursing 14 (11) 613-617,Department of Health (2004) The NHS Knowledge andSkills Framework (NHS KSF) and the Development ReviewProcess (October 2004) available for downloadhttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4090843 (accessed 24.08.08)Department of Heath (2007) Agenda for Change (ResourcePack) download from http://www.dh.gov.uk/en/Managingyourorganisation/Humanresourcesandtraining/Modernisingpay/Agendaforchange/DH_4112440 (accessed24.08.08)Duffy K (2003) Failing students: a qualitative study of the factorsthat influence the decisions regarding assessment of studentscompetence in practice London Nurse Midwifery Council (Download:http://www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=1330 )(accessed 24.08.08)European Commission (2005) Luxembourg Declaration on PatientSafety (see download http://ec.europa.eu/health/ph_overview/Documents/ev_20050405_rd01_en.pdf (accessed 24.08.08)European Oncology Nursing Society (2005) EONS Post-basicCurriculum in Cancer Nursing 2005 (3rd Edition) Brussels EONSdownload from: http://www.cancerworld.org/CancerWorld/getStaticModFile.aspx?id=902 [accessed 24.08.08]Gonzci A (1994) Competency based assessment in the professionsin Australia Assessment in Education 1 27-44Hussey T and Smith P (2002) The trouble with learning outcomesActive Learning in Higher Education 3 (3) 220-233Mallaber C & Turner P (2006) Competency versus hours: Anexamination of a current dilemma in nurse education Nurse EducationToday 26 2 110-114Moule P, Wilford A, Sales R, Lockyer L (2008) Student experiencesand mentor views of the use of simulation for learning NurseEducation Today 28 (7) 790-797National Cancer Nursing Education Project [EdCAN] (2008)National Education Framework – Cancer Nursing: A nationalprofessional development framework for cancer nursing CancerAustralia Canberra (Download from http://www.edcan.org/pdf/EdCanFramework1-6.pdf (accessed 24.08.08)Pietro, D A Shyavitz, LJ Smith R A and Auerbach S (2000) Detectingand reporting medical errors: why the dilemma? British MedicalJournal ;320;794-796 doi:10.1136/bmj.320.7237.794Schon D (1983) The Reflective Practitioner: How professionals thinkin action New York: NY Basic BooksSkills for Health (2008) Chemotherapy Framework http://tools.skillsforhealth.org.uk/competence/searchResults?keywords=Chemotherapy&framework%5B%5D=21&level%5B%5D=1&level%5B%5D=2&level%5B%5D=3&level%5B%5D=4&adv_search.x=36&adv_search.y=7(accessed 24.08.08)Topping A, Porock D, Watson R & Stimpson A (2002) Evaluation ofthe effectiveness of educational prepration for cancer nursing andpalliative care. Report to ENB/Department of Health. LondonWatson R, Stimpson A, Porock D and Topping A (2002) Clinicalcompetence assessment in nursing: a systematic review of theliterature Journal of Advanced Nursing 39 5 421-431Weatherall A (2004) National Care Competency http://www.city.ac.uk/sonm/dps/pre-reg-curriculum/references_usefuldocs/KSF%20Cancer%20Competencies.pdf (accessed 24.08.08)- newsletter fall 20086

Dungeons and dragonsExploring the EU policy context of cancer nursingSara Faithfull, EONS presidentOver the summer I have been working with an Erasmus studentfrom Germany who has been visiting the UK & Belgium as part ofa 3 month educational exchange to EONS as an Erasmus graduateapprentice from Saarland University. It has been an enlighteningexperience as we have both explored the “dungeons and dragons”of EU policy. I have marvelled at the bravery of my colleague ofleaving family and friends, going overseas and living in anotherculture. Although a novel experience and one that widens horizonsand challenges beliefs it is still scary. Differences in culture andhealth roles are much more than just in what people are called orwhat nurses are able to undertake in terms of nursing practice. Itmakes one examine what we also believe about Europe and multidisciplinaryworking. Learning the living language (i.e. the slangor colloquial talk) eating new foods and understanding differenthealth systems is part of learning from that experience. Despite allthese wider experiences our Erasmus/ EONS project is to map thepolicy context of cancer specialist nursing and identify how far nationalmember states have met or undertaken change as responseto these EU directives. It has been so far a journey of discovery.Our first step has been exploring the dungeons of EU policy. Letme explain going back to EU cancer policy basics.The Commission of the European Communities (CEC) Europeagainst cancer (EAC) programme identified the need for effectiveeducation and training in its first action in 1987. This wasreaffirmed in the second action plan 1990-94. The commissionrecognised the vital role of the different health professionalsboth in prevention and early diagnosis of cancer and encouragedundergraduate and postgraduate training on screening methods,counselling appropriate methods of treatment, rehabilitation andterminal care (EU 1997). The third action plan 1996-2000 consolidatedthis and encouraged new training initiatives such as theinclusion of psychosocial care. However it should be rememberedthat at that time that nursing was and still is largely a non graduateprofession in many countries and that these recommendationsreflect exchanges within centres of excellence and development oftraining networks. These networks have largely not been accessedby nurses.Later policy reflects discussion papers in relation to areas of needsuch as cancer care in the Baltic member states or specific tumourgroups such as cervical screening. They also reflect a predominantlypreventative strategy. Layered on top of this EU level arethe World Health and global propositions providing a complex mazeof guidance and policy. Furthermore, local and national initiativesneed to be considered at the level of cancer plans and cancerhealth service provision. No wonder few of us understand the EUpolicy context for cancer provision let alone in support of cancernursing!The dungeons of the game are that much of EU policy is in theform of recommendations i.e. providing guidance to member statesrather than binding. Policy is like a maze in that there are severalforms of advice from white and green papers providing discussionto that of directives becoming legally binding at a national level.Deciphering these levels is important in realising the power ofsuch statements in making or directing change and then finding ifany part relates to the provision of specialist cancer nursing. Thisis like exploring the dungeon without a light! Visiting EU policyexperts and talking with those developing new EU cross borderpolicy has been insightful. However, I can tell you so far we havefound that cancer nursing is mainly invisible at a policy context.The focus on prevention and cure leaves little discussion abouthealth care packages, communication skills, symptom managementor supportive care. Nursing is neither defined nor appraisedas part of prevention or treatment provision. We now come to ourdragons “multidisciplinary care”. What this means in EU speak isthe breadth of medical provision from surgeons to oncologists andnot encompassing nurses or health care providers. Even the recentSlovenian document, challenging the future burden of cancer care(2008) had chapters written by clinicians, patients and psychologistsbut not a nurse amongst them when considering the provisionof future care. Where are the nurses and why can’t they be seen?Partly I think this relates to the valuing (or lack of value) of specialistcancer nurses in many countries within Europe, but also thepaucity of firm outcome evidence that specialist cancer nursingprovides benefits for patients. Where such evidence exists forexample in breast care then nurses are visible within policy guidance.However nurses are largely seen as a supporting roles ratherthan professionals in their own right. You may feel offended by thistake on why nursing is invisible but how many of us have lobbiedpoliticians for nursing issues, written in to policy statements orinvolved ourselves at national policy level. To get out of the socalled dungeon we need to respond to policy statements, developour evidence that specialist cancer nursing maters and provide theleadership to make nursing count. Start by responding to the UICCworld cancer declaration 2008 (www.uicc.org) and make this a callfor action.newsletter fall 2008 -7

Lifelong LearningMentoring and Personal Development Planning in Health CareAlison Rhodes, Director of Studies – Learning and Teaching Framework, Faculty of Health and Medical Sciences, Division of Healthand Social Care, University of Surrey, Guildford, SurreyI was delighted to be asked to make a presentation at the EONSeducational event earlier this year, on topics that are my passion –mentorship and development.My motivation in these areas began some 20 years ago whilstworking as an Intensive Care Unit Sister, where pre-registration andpost registration students were placed to gain clinical experience.Through this time, I found myself experimenting with creative waysto not only develop the student’s knowledge and understanding butto also support them to not be fearful of such a high technologicalenvironment. It seemed so natural to facilitate development throughmentorship, and in fact, my mentorship role was and still is anexciting challenge and one that continues today. My enthusiasmfor these concepts led to my research in development and personaldevelopment planning (PDP), where I became interested in theconcept of the Learning Organisation and the provision of supportwithin the workplace for learning and development.My learning journey has culminated in my role as Director of Studiesfor the Learning and Teaching framework, which caters for thepreparation of mentors, practice teachers and qualified teachersat both undergraduate and postgraduate levels. In developing theframework, a curriculum was designed based on the Nursing andMidwifery Council’s (NMC) Standards (2006) which highlighted areasof responsibility and accountability through four stages (figure 1),relating to supporting learning and assessment in practice.Figure 1 – Stages identified within the standards (NMC 2006,Standards to Support Learning and Assessment in Practice [updated2008])STAGE 1STAGE 2STAGE 3STAGE 4ASSOCIATE MENTORMENTORPRACTICE TEACHERQUALIFIED TEACHER(NMC 2006)The framework was developed as an escalator (figure 2) withmentorship at undergraduate level, leading to the practice teacherand the qualified teacher at postgraduate level.Figure 2The underpinning philosophy (figure 3) of this framework was buildaround the concept of development. A new philosophical curriculummodel was designed (six-dimensional multi-faceted module ofdevelopment [Rhodes 2006]) integrating theory and practice in aprogressive way encouraging independence, motivation and criticalthinking.Figure 3 - PhilosphyAs highlighted on figure 3, the student is considered to be centralto this philosophical approach, giving an opportunity to explore pastexperiences, knowledge and aspirations.The majority of students enter the framework at stage 2 - thementorship module, where they are required to complete a PDP inthe form of a Learning and Development Plan. This plan takes thestudent through a number of activities primarily to explore their skillsin mentoring but to also explore the complexities of mentorshipthrough the integration of the concepts of teaching, learning andassessment in practice, leading to a practitioner who can assistothers on their journey of learning.The mentorship module has proved to be a very successful module- its strength lies in the positive relationship between students,practice colleagues and teachers, with very strong links to clinicalpractice, enhancing a journey of lifelong learning.References and further reading:Gopee N. (2008) Mentoring and Supervision in Healthcare. SagePublications, London.Nursing and Midwifery Council (2008) Standards to support learningand assessment in practice (2 nd edn.) [online] Nursing and MidwiferyCouncil, London. Available from: http://www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=4368Quinn F. & Hughes S. (2007) Quinn’s Principles and practice of nurseeducation (5 th edn.) Nelson Thornes, Cheltenham.Rhodes A.K. (2006) Learning and Teaching for Professional PracticeCurriculum Document University of SurreyWest S., Clark T. & Jasper M. (2007) Enabling Learning in Nursingand Midwifery Practice: a guide for mentors. John Wiley & Sons,Chichester.- newsletter fall 20088

New Education Standards for Nurses in TurkeyImplementation of Chemotherapy Nursing Certificate ProgramSultan Kav, Fatma Gundogdu, Nurgün Platin, Figen Bay Kara, Meral Bakar, Kadriye Sanci, Kıymet Akgedik, Oncology NursingAssociation of Turkey, Board MembersBackground and AimNurses caring for patients receiving chemotherapy requirespecialized knowledge and skills in order to ensure the safetyof both the patient and the nurse. In Turkey, while some of theuniversities and oncology institutes organize local courses, whichrange from 2- to3-days and are intended as in-service education,there is no agreed educational standard for nurses working inchemotherapy settings. Many Turkish nurses lack the necessaryinformation to care for patients receiving chemotherapy and havenot received education regarding safe handling or administrationof chemotherapy agents (Burgaz et al, 1999; Karadag et al, 2004;Turk et al, 2004; Kosgeroglu et al, 2006).In light of this situation, the Oncology Nursing Association ofTurkey developed a chemotherapy certificate program for nurses.The program has received approval by the Ministry of Health.Contents of the ProgramThe course is of 37 hours in length and consists of 27 hoursof theoretical and 10 hours of practical training. The durationof the course is five working days. The EONS Core Curriculumfor a Post-Registration Course in Cancer Nursing, the OncologyNursing Society’s (ONS) Cancer Chemotherapy Guidelines andRecommendations for Practice and, the needs of nurses weretaken into consideration developing the educational program.Theoretical and practical content of the ChemotherapyNursing Certificate ProgramTheoretical content- Carcinogenesis, epidemiology and etiology- Diagnostic procedures and treatment methods- Legal and ethical aspects- Basic principles of chemotherapy- Safety precautions in chemotherapy- Assessment and monitoring of the patient- Patient and family educationPractical contentVisiting a day-treatment unit with supervision provided by adesignated mentor. Each participant administers at least fivedifferent groups of chemotherapy agents.CertificateParticipants who successfully meet the expected achievementare issued the “Oncology Nurses Association ChemotherapyCertificate”. The certificate is valid for three years and must berenewed.EligibilityThe registration requirement for the course is at least 6 months ofexperience in chemotherapy administration.Educators /TrainersThe theoretical content of the course is delivered by clinicaland academic nurses experienced in the field of oncology,pharmacologists and medical oncologists. During the practical partor the hands-on parts of the program, participants are supervisedby experienced clinical nurses.Evaluation of the ParticipantsThe participants are evaluated on the basis of their hands-onpractice (100 % performance is expected) and the result of thewritten theoretical test (at least 80 % performance is expected).Pre-test / post-test evaluation is used to monitor individual andgroup achievement.Implementation of the ProgramFrom September 2005 to February 2008, total of ten courses wereorganized in Ankara and 306 nurses (from all over the country)were issued a chemotherapy certificate. According to the pre-testand post-test scores, the nurses showed a great improvement intheir understanding of administering chemotherapy and monitoringside effects.Figure 1: Pre-test and Post-test Results (Means)Conclusion and Plans for the FutureOverall, participants rated the courses “highly beneficiary” andstated that they became “more confident” with the care of thechemotherapy patient. Recently “The training of the trainers”program was organized for the potential educators of the program.A study on the assessment of the effectiveness of the program onthe care of the nurses is being planned.ReferencesBurgaz S, Karahalil B, Bayrak P, et al. Urinary cyclophosphamideexcretion and micronuclei frequencies in peripheral lymphocytesand in exfoliated buccal epithelial cells of nurses handlingantineoplastics. Mutat Res 1999; 439: 97-104.Karadag A, Unlu H, Yavuzarslan F, Gundogdu F, Kav S, TerziogluF, Taskin L. Profile of nurses working in oncology departments inTurkey. Turk J Cancer 2004, 34: 24-34.Turk M, Davas A, Ciceklioglu M, Sacaklioglu F, Mercan T.Knowledge, attitude and safe behaviour of nurses handlingcytotoxic anticancer drugs in Ege University Hospital. Asian Pac JCancer Prev 2004; 5:164-8.Kosgeroglu N, Ayranci U, Ozerdogan N, Demirustu C.Turkish nurses’ information about, and administration of,chemotherapeutic drugs. J Clinl Nurs 2006; 15: 1179–1187.newsletter fall 2008 -9

Patient Diary Project receives 2008 EPE AwardAn interviewEONS newsteamThe recipients of the EPE award 2008 are Mrs. Catherine Oakleyand Mrs. Jo Johnson for their project ‘Patient Oral ChemotherapyDiary’. The diary was developed to provide a robust generic methodof supporting cancer patients and their carers, to manage oralchemotherapy treatment.The Excellence in Patient Education (EPE) Award was launched in2005 with the aim of honouring individual nurses or organisationsthat have consistently excelled at enlightening cancer patients abouttheir disease and its treatments. EONS believes that this Award willencourage creative and cutting-edge approaches to the developmentof patient education materials.In an interview with Jan Foubert, the winners of the 2008 EPE Awardprovide insight into the background, development, and future of theirpatient education project.Q: At a time when so many patient diaries are provided in all kindsof written form including on the internet and on CD, what led you toconsider producing this kind of format for your patients?A: There are many diaries currently in circulation but they arepredominantly orientated to one brand or method of administrationof oral chemotherapy. We reviewed a large number of diaries duringthe initial stages of designing our diary, and were not able to identifya generic diary which was grounded in research or completelypatient-driven. These elements were both considered essential infacilitating an outcome which could be used across tumour types andbe considered as evidence based.We have considered all modes of delivery. However, a significantproportion of the patient population receiving oral chemotherapy stilldo not have regular access to a computer or feel confident using one.Some of the patients who were interviewed as part of the researchcommunicated that although they had been given both the electronicand paper versions of previous diaries, they favoured the paperversion. This was due to the fact that they were more confidentmanaging this format and that they could carry it with them at alltimes. We would be very keen to develop this diary via a hand heldcomputer device. A further step could be provision of a computeriseddiary to enable pharmacy staff to complete dose scheduling ofmedications electronically and print this information for patients.Q: Is this diary user friendly? How has it been evaluated and used byboth patients and nurses? What are the major key issues and concernssurrounding the care of patients undergoing oral chemotherapy?A: This is a newly developed diary which has recently beenimplemented. It was developed in consultation with patients whotold us what they would like to have included. The diary provides aneducation focus as it provides key information related to self carein terms of managing treatment administration and action to betaken to minimise toxicities. The diary is being used in one healthservice trust within the South West London Cancer Network with aview to extend use to other constituent trusts. At the host trust theindividual patient scheduling regimen is added to the diary by thepharmacy. The diary and chemotherapy tablets are dispensed to thechemotherapy nurse. Patients then have a separate appointmentwith the nurse who provides education including use of the diary.Only when the nurse is confident that the patient can manage thetreatment is this handed over. The session also includes a check listwhich prompts the nurse to educate the patient, assess supportivecare and to ask questions designed to assess a patient’s ability tomanage their oral chemotherapy.The diary has been evaluated with patients through research carriedout by Jo Johnson. This study demonstrated that patients found thediary to be a useful aid to managing their treatment. The schedulingpart of the diary provided a useful prompt to remind patients whento take their tablets. Patients also like to tick doses off when takento help prevent incorrect scheduling (Oakley, Plant and Bloomfield,2006). Participants particularly appreciated the “traffic light system”which alerts them to which symptoms should be reported promptly.It is out intention to role out the diary across two cancer networks forsix months. At this time we will carry out separate focus groups withpatients and staff who are familiar with using the diary.We feel that there are several major key issues and concerns forpatients prescribed oral chemotherapy. Firstly, there is often anunstructured approach to oral chemotherapy services with a lack ofassessment, education, monitoring and support. Patients and carersseem to feel the responsibility of managing their treatment alonewhich can be and overwhelming (Oakley, Plant and Bloomfield, 2006).Patients are not usually able to assess when to interrupt treatmentand nurses don’t generally provide proactive monitoring and supportservices. Anecdotal accounts suggest that patients prescribed oralchemotherapy often don’t phone the hospital when toxicities occur.Postulated reasons for this include patients are not knowing able torecognize severe symptoms and patients deny that side effects willoccur (Oakley, Plant and Bloomfield, 2006) and patients do not wantto interrupt treatment which they urgently want to take to treat thecancer (Chau et al, 2004).Q: In the application you refer to a study (Johnson 2008) which isawaiting publication, can you explain more?The study quoted is part of a Master’s degree which was completedin April 2008. This study is now being formally written up forpublication (Autumn 2008). The results of this study will also be usedin conjunction with the results of the study by Oakley (2005), to allowpublication of an in depth overview of the entire research. An articleproviding a summary of the programme and a pictorial overview ofthe diary has just been published in Cancer Nursing Practice (Oakley,Johnson and Deeprose 2008).Q: For which kind of patients is this diary intended?A: The intention is to use the diary for patients receiving anti-canceroral chemotherapy treatment and the diary has been designed toaccommodate all current oral chemotherapy regimes. Followingevaluation of the diary within colorectal cancer and haematologicalmalignancies, we have made adaptions to include both weekly and28 day cycles. As most haematology regimens run over 28 days,patients within the study struggled to use the weekly equivalent.Patients who have reviewed the diary following this amendmentreport that the instructions on the first page provide a clearexplanation of how to use the two different cycles.Q: How many copies of the diary have been distributed so far?A: 100 diaries were printed (2nd version) and used as part of theresearch process. This diary is now the 4th version, with changes- newsletter fall 200810

made in response to patient feed back from the study and evaluationfrom health care professionals. We are currently in the process ofrolling out the diary across the South West London Cancer Network(SWLCN). In the interim, we have secured a print run for 300 copiesof the latest version, which will be used within St George’s Hospital,to continue the excellent model of care introduced to support the useof the diary.Q: What attempts have you made to evaluate use of the diary?This diary has been evaluated at every stage of its development. Theinitial versions were evaluated by primary, secondary and territorycare providers within the SWLCN. It was also evaluated by patients,both within the context of the Diary Development Group and theSWLCN Patient Partnership. The final versions have been evaluatedformally and informally within the units caring for these patients. Wewanted to find out the practicalities of using this diary and also valuedthe varied feedback from healthcare professionals. All feedback hasbeen examined, interpreted and used to shape the final version of thediary.Q: How have you changed the diary to reflect the comments made bypatients?A: The patients’ responses and comments to the diary have driventhis programme from the outset. We were able to work with anumber of patients who had recently undergone a course of oralchemotherapy, thus enabling us to gain a good insight into theproblems encountered.Q: Have any particular groups or minorities had problems using thematerials?A: The initial research study had to exclude patients who did nothave English as their first language for funding reasons. This was afeasibility study and was not attached to any external funding. It isnot possible to predict at this stage whether any particular groups orminorities would have problems using the diary and further researchis required to explore this.Q: What about minority groups? Have you thought about translating itinto other languages?A: We would like to evaluate the diary further before it is translatedinto other languages. These would reflect the ethnicity of our localpopulation.Q: Did you have support to produce the diary?A: Up to this point the diary has progressed and been producedthrough good will! Our graphic designer is a family member andhas worked on the design and creation of each version of the diaryfree of charge. The initial batch of printing was carried out free ofcharge through an independent company who wished to support theprogramme. The majority of the work for this programme has beendone in our own time.us to fully evaluate the model of care chosen to support the diarywhich we hope can be adopted by other providers to improve themanagement of oral chemotherapy patients.Q: How will you use the prize money from the EPE award?A: We are going to use the prize money to fund education. This willallow us to extend our existing skills and knowledge and to be able totake this work forward effectively.Q: What was the most valuable thing you learned from undertaking theproject?A: The most valuable lesson we learned was the importance ofpatient involvement. One of the most poignant moments of theprogramme occurred during a meeting of the Diary DevelopmentGroup. Following long discussions and healthy debate over thepossible contents of the diary, one patient spoke up and asked ‘Isthis diary going to be designed to meet your needs (the healthcareprofessionals) or ours?’ This patient completely refocused the groupand his words stayed with us throughout the diary’s developmentGrounding the development of the diary within the research processhas also been invaluable. It has provided us with a clear beginningand end point, thus allowing structured evaluation.Q: What advice would you give to others who might be thinking aboutdoing something similar?A: It is important to form a project group from the outset whichincludes both patients and representatives from all providers. A clear,structured project plan is essential and should include realistic timelines and deadlines for completion. This maintains the momentumand allows simple monitoring of all progress. Four versions ofthe diary were produced in total. All of these versions have beencommented on by the Diary Development Group, as well as beingsent out for wider consultation throughout the SWLCN.Q: Are there any other members of the production team that you wouldlike to thank?Yes, we would like to thank the Diary Development Group, inparticular the patients and staff who gave time to the project andsupported us through this long and at times stressful process. Weare also very grateful to the continued support from Mark Deeprose,our graphic designer. Without him we would not have been ableto transfer our vision and ideas into print. We also are indebted toKing’s College, London. We both completed our MSc studies thereand received a significant amount of additional support with the diaryfrom Dr. Emma Ream, our shared supervisor and role model. Andlast but not least, we extend thanks to our families for putting up withus!Q: This is a rather involved project. How long did it take to produce thediary?A: Three years.Q: Did you receive funding to conduct the project?A: The research study was not associated with any funding. Wemanaged the overall programme with minimal funds. Refreshmentsfor meetings and reimbursement for patient travel costs wereprovided by the South West London Cancer Network.Q: Do you have plans to develop the project further?We would like to formally evaluate the introduction of the 4th versioninto practice to enable us to roll it out more widely. This will allownewsletter fall 2008 -11

Cancer UpdatesResults Policy and ProgrammesReport provided by Jan Foubert, Executive Director EONSCONCORD Study shows Large Differences in Cancer SurvivalWorldwideThe CONCORD study ‘Cancer survival in five continents: aworldwide population-based study’ by Prof. Michel Coleman et aland the CONCORD Working Group was published online in LancetOncology on 17 July 2008. It is claimed that it is the first worldwidestudy designed to quantify international differences in populationbasedrelative survival by age, sex, country and region for patientsdiagnosed during 1990-94 with breast, colon, rectum or prostatecancer. The study provides data on 1.9 million adult cancer patients(aged between 15 and 99) from 101 cancer registries in 31 countrieson 5 continents.Key points from the study include:5-year survival for breast, colorectal and prostate cancers wasgenerally higher in North America, Australia, Japan, and northern,western and southern Europe, and lower in Algeria, Brazil, andeastern Europe.For colorectal cancer, 5-year survival for patients ranged from around60% in North America, Japan, Australia and France and down to40% in Algeria, Brazil, Czech Republic, Estonia, Poland, Slovenia andWales. Pooled 5-year survival for Europe ranged from 45% for womenand 48% for men. Almost 11% of patients with colorectal cancer diewithin the first month after diagnosis.For breast cancer, 5- year survival for patients ranged from 80% ormore in North America, Sweden, Japan and Australia to less than60% in Brazil and Slovakia, and below 40% in Algeria. Pooled 5-yearsurvival in Europe was 73%. About 2.3% of patients with breastcancer die within the first month after diagnosis.Survival from cancers of the breast, colorectal and prostate variedwith the type of health insurance in a population based study. Survivalwas highest with patients who had insurance (private or otherwise)and lowest with no insurance.Most of the wide variations in survival are likely to be due todifferences in access to diagnostic and treatment services.For further reference, please consult http://www.thelancet.com/journals/eopCurrent Trends on Cancer Incidence, Mortality and Survival inEuropeThe European Journal of Cancer (EJC) published a special editionon ‘Cancer control in Europe, state of the art in 2008’ on 2 July2008. The issue features ten articles on the cancer burden and onrecent trends in cancer survival. In an overall analysis of the papers,co-editors Prof. Jan Willem Coebergh (The Netherlands) and Dr. TitAlbreht (Slovenia) conclude that cancer prevention and managementin Europe is moving in the right direction. Differences betweencountries in policies for mass screening, access to healthcare andtreatment, however, are reflected in varying cancer rates. The mainconclusions of the articles include the following:• In the more prosperous countries of Northern and Western Europe,cancer incidence shows a downward trend, with the exceptionof obesity-related cancers (such as colorectal cancer), and fortobacco-related cancers in women;• Due to better access to specialised diagnostics, earlier detectionand better treatment, EU-wide survival rates for most cancers haveimproved;• The highest incidence rates of breast, prostate, testicular cancerand melanomas were observed in Northern and Western Europe,while lung, stomach and cervical cancer were more common inSouthern and Central Europe.• Cancer prevention efforts must be improved, in particular withregard to female smoking and the emerging obesity epidemic.Prof. Coebergh and Dr. Albreht expect the special issue to providerelevant input to the drawing up of the European Commission’sforthcoming Action Plan on cancer. For further information, also seethe press release from the European CanCer Organisation (ECCO)and on the website http://www.ecco-org.eu:80/News/News/In-the-news and on http://www.sciencedirect.com/science/journal/09598049.EUROPA DONNA to launch Breast Health Day in Europe on 15October 2008The European Breast Cancer Coalition (EUROPA DONNA) willlaunch a Breast Health Day in Europe on 15 October 2008. A pressconference featuring expert speakers will take place in Milan in thelate afternoon.The aim of this initiative is to start a public education campaign toensure that women and girls across Europe have correct informationon the early detection and prevention of breast cancer. The ultimategoal is to reduce incidence rates as a result of immediate actionon breast cancer. To increase public awareness, EUROPA DONNAis preparing a short public service TV announcement, which will beaired in 41 countries in October. Representatives of the 41 membercountries of EUROPA DONNA, including all 27 EU countries, willbe present at the launch. The new “Short Guide to Breast Health”which covers lifestyle factors influencing breast cancer, as well asthe “Short Guide to the European guidelines for quality assurance inbreast cancer screening and diagnosis” (see www.cancerworld.org),will be discussed at the event.EU Health Ministers adopt Council Conclusions on CancerThe EU Health Ministers adopted Council Conclusions on reducingthe burden of cancer at the Employment, Social Policy, Health andConsumer Affairs Council (EPSCO).While highlighting the cancer burden and the expected increase incancer incidence in an ageing population, the Conclusions call fora patient-centered, comprehensive and interdisciplinary approachto cancer control. They further point at the existing inequalitieswithin and between Member States with regard to cancer incidenceand survival rates. As a key element, the Conclusions stress theimportance of cancer registries and cancer control strategies, as- newsletter fall 200812

well as the need for greater cooperation between care services atdifferent stages of the cancer cycle.Underlining prevention as the most effective long-term strategyto reduce the burden of cancer, the Conclusions reiterate theimportance of healthy lifestyles and the reduction of occupationaland environmental carcinogens.The document also welcomes the involvement of civil society, inparticular patient groups, in shaping cancer policies and developingservices to better address patient needs.Among other actions, the Conclusions invite Member States to:- Develop and implement cancer strategies or plans;- Continue the implementation of cancer screening programmes inline with the Council’s Cancer Screening Recommendation (2003);- Provide the best possible evidence-based treatment for cancerpatients within the framework of national health priorities andfinancial resources;- Ensure population-based cancer registration as an important toolfor the development and monitoring of policies to prevent and treatcancer;- Take advantage of existing financial mechanisms to improve cancerprevention and control and also exchange best practices in thesetwo fields.The Conclusions further invite the European Commission to:• Present an EU Action Plan on Cancer addressing cancer controlfrom prevention to palliative care;• Facilitate the exchange of best practice and encouragecooperation in the evaluation, monitoring and assessment of healthactions;• Support Member States in the implementation of the Council’sCancer Screening Recommendation;• Support the networking of cancer registries;• Extend the knowledge of cancer, e.g. with regard to risk factors,early detection and treatment.Finally, Health Ministers encourage representatives of civil society toactively participate in raising awareness of cancer risk factors and ofscreening and prevention programmes. The Member States and theCommission should also promote the empowerment of civil society;these should contribute to the development and implementation ofcancer strategies or plans.At the Health Council meeting Slovenian Health Minister Zofija MazejKukovič outlined the main elements of the Conclusions, emphasisingthe growing cancer burden despite progress made in preventionand treatment to date. EU Health Commissioner Androulla Vassilioureiterated that the Commission will put forward an EU Action Plan onCancer in 2009, which will be accompanied by an impact assessmentof the human, social and economic costs of cancer. She also saidthat much remains to be done to implement the Council’s ScreeningRecommendation from 2003.In the national speeches, national and/or regional cancer strategiesand plans emerged as the most common topic of interest. Forinstance, Portugal called for cooperation between the MemberStates in developing national cancer strategies while Spain stressedthat regions must have an input in European cancer strategies. TheHealth Ministers also outlined national screening and preventionpolicies, with an emphasis on lifestyle-related initiatives. Finally, theyhighlighted the importance of cooperation on research and exchangeof best practices.Endorsed by the Health Ministers of all Member States, theCouncil Conclusions on cancer reflect broad political support offurther action to reduce the cancer burden and the existing cancerinequalities across Europe. Together with recent European Parliamentinitiatives on cancer, such as the Resolution on combating cancerin the enlarged EU, the Council Conclusions pave the way for acomprehensive EU Action Plan on cancer to be introduced by theCommission in 2009.PREVENTPrediction, Recognition, Evaluation and eradication of normal tissueeffects of radiotherapy11-12 th January 2009 Brussels, BelgiumThis ESTRO conference, in collaboration with EONS, explores thescience and clinical knowledge of radiotherapy side effects. This twoday conference brings together scientists, clinicians and nurses tofocus on the important issues of radiation toxicity and explores theimpact and future management for patients. The plenary speakerswill present the latest radiotherapy research and discuss the clinicaland scientific issues facing clinicians in the management of patientsundergoing radiotherapy including acute and late effects. Thisconference is aimed at health practitioners working in the field ofradiotherapy or caring for patients who receive or have receivedradiotherapy.Mains sessions explore radiation induced cancers, radiation biologyand mechanisms of normal tissue damageParallel clinical sessions will explore:• Impact of toxicity on patients• Measurement of toxicities• Managing toxicitiesSpeakers include both nurses and clinicians researching this fieldand providing the evidence base for radiotherapy management anddiscussion of where our gaps in knowledge exist.For further information of the scientific programme and registration:http://www.estro.be/estro/index.cfm or contact the ESTRO officeon 0032 2 775 93 40.newsletter fall 2008 -13

EONS, Eusoma, ESSO Training ProgrammeReport from the participantsJan Foubert, EONS representative on this Training Programme.Regular readers of the EONS Newsletter may recall an articlepublished in the Winter 2007 issue which announced the recipientsof a traineeship supported by Eusoma, EONS, and ESSO. Theaim of this educational initiative is to train specialist health careprofessionals to better deal with patients with breast cancer.Following a very successful call for applications for the traineeships,five EONS members were chosen to participate in a one-monthvisitation to a European breast care center. As you will read below,both recipients made the most of the opportunity to learn more aboutnursing care of the patient with breast cancer and to extend theirnetwork of European colleagues.Lara Kaligaric from Slovenia was selected to attend a clinicaltraining programme in the Senology Department, FondazioneSalvatore Maugeri, Pavia, Italy, here follows her impressions of thetraineeship:Although the approach to care was multidisciplinary on this breastunit, most of my traineeship was concentrated on interaction with thenursing staff. I had the opportunity to observe different procedureswhile working on the unit as well as observing procedures in theoperating room. I found the experience of assisting in the operatingroom particularly interesting as I had never before done this type ofnursing.Experiencing the interaction and collaboration between oncologistsand plastic surgeons was new for me as plastic surgeons are not partof the oncology team at my ‘home’ institution. I also gained newknowledge by participating in multidisciplinary sessions where patientcases and treatment options were discussed.Although I am sure that I have developed new competencies throughmy experience, the one-month duration of my traineeship was tooshort for these newly acquired skills to really show themselves. Ihave learned some new aspects of cancer care that I will certainly beable to use in one form or another when I return to my place of work.These are:• The importance of developing a relationship with the patient priorto surgery;• Different patients have different needs: some want to knoweverything about their illness while others just want to have surgeryand get on with their lives;• Sometimes the best nursing care is to just be quiet and listen tothe patient.The training was a good experience however what I observed wasnot so very different from the situation on my ‘home unit’. Beforeundertaking the training I was very motivated to initiate change andstill am! On the unit where I work we care for patients with all typesof cancers so it will be somewhat difficult to implement all of what Iexperienced. I would like to eventually work in an outpatient settingwith women who have different stages of breast cancer undergoingdifferent types of treatment.Marjia Adamovic from Serbia did her traineeship at the CancerInstitute-Antoni van Leeuwenhoek in AmsterdamMy one-month traineeship in a specialized, high-standard institutionlike The Netherlands Cancer Institute-Antoni van Leeuwenhoek(NKI-AVL) in Amsterdam was a great experience for me that widenedmy knowledge. I had an opportunity to visit the operating rooms, theinternal medicine department, the outpatient clinic for chemotherapy,the radiology department and the department for creative therapy.My attendance at the interdisciplinary meetings was especiallyrewarding. Contact with patients really increased my understandingof the role of cancer nurses.Working in the medication preparation room, which was speciallydesigned to protect nurses and pharmacists from contact withhazardous agents, taught me a lot about the proper handling ofchemotherapy agents. That is something we do not have at theInstitute for Oncology and Radiology of Serbia.In everyday work with kind and helpful colleagues, I gained insightinto new protocols to treat breast cancer and other malignancies.I also saw a new generation digital mammography in practice andstereotactic biopsy used as a diagnostic procedure.What I found most intriguing was the organization of the institutewhich is centered around the patient and many procedures, forexample MRI, are performed within one day. I also was surprisedthat breast reconstruction is paid by the social insurance fund. Theaccommodations for patients are spacious and brightly decoratedand there are meditation rooms for both Christians and Muslims.Patients and their families can easily access information which isavailable in leaflets, books, internet and open phone lines.Workshops and creative therapy play a big role in the psychologicalaspect of patient care. I met an elderly lady who was receivingchemotherapy and happily chatting about a necklace she was makingin creative therapy. Concerts are held every month for patients.All these experiences left a big impression on me and I hope that oneday we will have the facilities and resources that I saw at the CancerInstitute-Antoni van Leeuwenhoek at my institute. Although wecannot offer patients the same treatment as offered in Amsterdam,we give our best, we use what we have, and we try to makeeverything easier for them.Elizabeth Vella from Malta went to Burney Breast Unit in WhistonHospital in Prescott Merseyside.My one-month traineeship was positive and an excellent learningexperience. Although I had had an opportunity to attend the course‘Care of the Patient with Breast Cancer’ at the Royal MarsdenHospital in London, actually experiencing first-hand how things aredone and being present as part of the team on the Burney Unit was amuch more enriching experience.Burney Breast Unit is situated within Whiston Hospital and coversa population of 360,000. The breast service is staffed by a team ofdedicated clinicians and specialist nurses. The team detects andtreats over 200 new cases of cancer each year. I had the opportunityto attend a variety of services offered by the clinic, such as rapidaccess, non-urgent, follow-up and clinical trials clinics. I alsoparticipated during surgical procedures, in the chemotherapy unit, atoncology consultations, and during reconstructive/plastic surgeonconsultations.Mr. R Audisio under whose patronage I was entrusted, kindly invitedme to attend clinic sessions. Although my main interest was toobserve, share and work with the specialist breast care nurses,watching surgical procedures which have not yet been introduced inMalta, was interesting.- newsletter fall 200814

Being in various clinics once or twice a week for a month’s time gaveme the opportunity to follow patients through the first part of their‘cancer journey’. The breast care nurse is present when the patientis diagnosed, when she is being prepared for surgery when histologyresults are discussed and again when the oncologist explainstreatment options. The breast care nurse is a constant companionthrough the cancer journey, providing support, counselling andinformation for both patient and family.My learning experience was enhanced by the time I spent shadowingthe breast cancer nurses. I learned a lot from their gentle butcomprehensive and diligent approach toward patients. We are stillin contact and I feel this is one of the most important outcomes ofthe traineeship: meeting with professionals who work in the samearea and learning from each other’s experiences in order to provide abetter service for our patients.Attending the oncology clinics was one of the highlights of thetraineeship. The oncologist explains in a comprehensive and detailedmanner the treatment options and their side effects. Patients arethen given written information and are asked to ‘think about it’ and tocome back the following week with a list of questions. This enablespatients to make informed treatment decisions. Unfortunatelyour oncology clinics are not so well equipped. We have only twooncologists in Malta who see all the patients diagnosed with anycancer in the whole of the island. Ideally we should have a specialistbreast oncologist as a member of the multidisciplinary team.I’ve had discussions with my colleagues in Malta regarding somechanges in our service. We are considering to each have an individualpatient load and to maintain better nursing records. It has beendifficult for us to provide this specialist care since we have nosupport or clerical staff on our team and we spend much of our timepreparing for clinics and meetings.Vesna Kodzopeljic from Serbia attended the University Clinic inAachen, Germany. Her visit to this breast centre has been extremelyuseful and helped her to justify previous knowledge and skills. Shenoticed that all activities at the clinic are standardized. She hadthe opportunity to take part in obtaining lab specimens, changingdressings, working with the surgical team, assisting during biopsyprocedures and observing other medical and surgical procedures.This training has great influenced Vesna and will stimulate here tomake some changes in her daily practice.The first thing that Vesna is going to apply to her work environmentis the multidisciplinary approach toward patient care including thecollaboration of a psycho-oncologist which she believes will improvethe care provided to patients and their families.10 th World Congress of Psycho-OncologyInternational Psycho-oncology Society (IPOS)Report by Sara Faithfull, EONS presidentThe theme of this conference was: “Advancing culturally diverseapproaches in psycho-oncology and palliative care. Psychologists,clinicians and nurses were represented at this conference thatpresented overviews and recent research in the field of psychology.Symposiums covered how suffering and pain are related examiningthe relationship between symptoms and psychological distress. MartaSchroder and Debra Koatz (1L-2 2008) in a study of Spanish cancerpatients needs found that few of the 25 reviewed hospitals providedpsychological or emotional care services. They also found thatpatients who had unmet psychological patients need later developeddistress. They concluded that a greater appreciation of psychologicalneed early in the treatment trajectory could lead to better care.Screening for distress was a common theme in that we are all awareof the association between anxiety and distress.The EONS symposium (16) explored crossing boundaries: Etechnology and patient care. The idea of this symposium was to lookat work in progress on communication support provided throughtechnology to enhance patient‘s care experiences. Paz Fernandez-Ortega from Spain opened the session with some of the future careissues in assessing patients remotely and the need for new modelsof care. Roma Maguire from Stirling Scotland described existingresearch work on the ASyMS study on remote monitoring and itssuccessful use in patients receiving chemotherapy. Sara Faithfullfrom England presented work on the role of the workforce andattitudes in implementing telehealth systems and Nynke de Jong fromthe Netherlands described pain symptom management technologysystem that are being utilised and evaluated in clinical practiceto reduce cancer patient distress. The symposium was a greatsuccess with discussion of the role of technology in providing remotesupportive care.It was a common theme in many of the papers that there continuesto be a need for greater education and training in communicationskills and guidelines for assessment and management ofpsychological problems as a result of cancer.newsletter fall 2008 -15

Diversional activity deficitRecreation and activities in the oncology settingPatrizia D’Amico, Roberto Quarisa, Servizio di Oncologia Medica, Ospedale di Ivrea (TO), Italia, translation of the original version ofSarah Liptrott, European Oncology Institute, Milano“Diversional activity deficit” is one of the nursing diagnoses identifiedfrom the NANDA in 2005 (00097, II, 2005).The work of ‘recreation’ has progressed now for 10 years in thedepartment of oncology at Ivrea Hospital, near Torino, and is aconcrete response to this diagnosis. It consists of a general series ofinterventions, between the areas of creative activity and occupationaltherapy, to be performed when the onset of inadequate activity of thepatient is identified or anticipated.We work in a medical oncology department, composed of aninpatient unit with twelve beds, a day hospital, an outpatient serviceand a service welcome centre (CAS). Our ‘users’ are adults, usuallyover 50 years of age.Participating can take attention away from the symptom – it can bereduced or disappear temporarily. Also immobility is not an obstacle,some small pieces of work can be carried out in bed, surpassingphysical handicap. Sometimes the participation stimulates leaving thebed area and taking individuals to a communal area.EnvironmentCarrying out this activity allows us to go and to act in an environmentthat constantly changes because it is staged and modified accordingto the different seasons and for the different events that characterizeour lives. The time outside of the ward becomes lived also inside withpreparations created by the patients and personnel. The seasons –holidays like Christmas, Epiphany and carnival, so important in ourtown for the oranges-battle! – are remembered in our ward: the snowthat comes down from above, the flags of the carnival, grapes andautumnal leaves… recreate symbolic objects that evoke the “time” ofdaily life.In alternative to these moments, each person researches topicsaround which to create the objects of the projects: Threedimensionalanimals made with card, rubbish bags, glue, colouredcard, plastic bottles; coloured stained-glass windows made with cardand tissue paper;Larger objects; showcases for the postcards and for the photographs;large cardboard silhouettes.Usually they use cheap materials, recovered, recycled (above allpacking materials), easily available. However we have available forevery activity scissors, glue, staplers, string, adhesive tape, wire,thumb tacks, fishing line, coloured cards, tempera, paint, felt-tip pen,tissue paper, crepe paper.In our hospital as in the majority of hospital departments in Italy, theabsence of pleasant and diversional activites and the cold and clinicalenvironment, emphasize and sometimes increase the perception ofthe symptoms and the sense of isolation that oncological illness cancause. Also if the range of service ‘users are diverse in relation to ageand social status’ , the problem can be amplified. Depressed statesand apathy are often present in these types of patients.Throughout these activities, we aim to face the onset of theseinconvenient situations. Our recreational interventions aimessentially to make participants profit from light creative activity to fillthe long empty spaces of hospitalization.The activity is proposed to every individual, dedicating the timedeemed convenient; it is personalized allowing creativity, manualability, artistic skill and potential, even if this means discovering anability that they did not think they had. Also where there are highlevels of fatigue, they can participate, showing therefore that even thepresence of the symptoms leaves some margin for activity.The choice of the topic to be developed is by chance – a proposalfrom whoever has an idea: users, family, personnel… will find ideaor activity they like, begin work and leave it on the table in thedepartment and very slowly it is built upon. We aim to realize everyproposal, looking not to be repetitive, and for this reason, at theend of the period, the arrangement is dismantled completely andeliminated, recycling only the material still useable. In this waywe do not run the risk of same projects every year, stimulating theconstruction of new ideas.Often the project is not of high quality and during its realisation smallinconveniences occur or the aesthetic result is not that desired. , Forus it is not important, the thing that we aim for is participation in theaccomplishment…all that is realized, is meaningful for the individual.Timing• The long moments of inactivity that characterize a hospitalizationbring into focus the changes in life that cancer causes, redefininglong term objectives and often favouring a state of depression.These recreational interventions aim to allow individuals whowish to participate in different activities, to avoid the situation ofdepression.- newsletter fall 200816

This happens not only with the creation of projects, but also withdifferent interventions that involve the user in social games, theaccomplishment of a puzzle, reading of a book chosen from themany available in the library. There are then moments of fun in whichto assist like onlookers listening to some songs, musical groups orwatching entertainment shows.AtmosphereThe structural interventions are aimed to be more welcoming tothe environment, the work of collaboration between personnel andusers for the accomplishment of the projects, participation as simpleonlookers to the events: are all elements that contribute to changethe “atmosphere”. The climate is defined as an integration betweenphysical environment and social aspects, relations and emotions thatcharacterize an organization.Our intention is to create a family atmosphere, warm and attentiveto the human dimension in providing a positive quality careenvironment.. Sometimes during the recreational activity, nurses,patients and carers find themselves around a table together, whichbreaks down the professional/institutional structure and allows amore human dimension providing exchange and ‘chatting’ to knowmore personal aspects, taste, episodes of life not usually recalled innormal hospital interactions.It is these “chats”, exchanged in friendship, that often help toestablish answers to inexplicable reactions, reveal family dynamics,unexpressed fears, elements that become a valid help for our activity,and that allow better individualised care.The participation in recreational activity otherwise allows differentusers to know, or to be familiar with them, to go out from their roomsand to share with the others….This recreation often takes place also with the family, for them thisrepresents a diversion that allows temporary removal of the attentionof worries bound to the illness of the person for whom they care.The project started in 1997, driven bythe corporate training center and aimedat students participation. The initialstages included some nurses and theactivity was aimed at group-work andplaying rediscovery . The project was thenmanaged totally by nurses in the generalmedicine department and successively inoncology, and from the start it has beenself-financed. The time dedicated is almostentirely within normal working hours, dueto diversional activity being developedconcomitantly with the activity in the department.Within the Italian Oncology Nurses Association (AIIO), a study groupnamed Grano (oncology recreation group) established in 2004collected information about the Italian reality of the development ofexisting light, artistic, and recreational activities.One of the first objectives of the group was to map within Italy theconsistency of the diversional activity in non-paediatric oncologydepartments. This enquiry has emphasized the scarce attention tothis problem and the scarce interest, maybe correlated to a lackof knowledge in this subject that this aspect of humanisation andrelated activity are covered in the nursing profession.The AIIO National Congresses of and other educational courseshave been organized with the objective of conveying theory andtechniques of recreational interventions to make nurses aware ofthese less ‘scientific’ aspects of care, but that are equally importantfor our activity. After these episodes of training/education, thereality has begun to dawn on their services. To increase further thecirculation of the awareness of the diversional techniques, they havebeen put onto the AIIO website – a space that collects the blog ofsome services. Besides documenting activity carried out, the blogconstitutes a cue for those who want to begin to enliven the actualworking reality. The site AIIO is found at: htpp://www.aiio.itThe carrying out of recreational activity has been valid help toimprove the work of the team, all the activities are carried out thanksto the support of the health care professionals.newsletter fall 2008 -17

E-learning in cancer educationExploring the potentialGraham G. Dark. Centre for Cancer Education, Newcastle University, Westgate Road, Newcastle upon Tyne, NE4 6BEEveryone learns all the time, using agood and bad content and thereforevariety of means, but the initial hypethe skills of navigating and locatingof promise from e-learning was metthe right information at the right timeby resistance and a perception ofwill be key. Trusted providers of highinferiority. What everyone missedquality knowledge and learning willwas that ‘e-‘is only the methodprevail in this global market.of delivery and that the impact ofthe education was dependent onLearning technology has introducedthe quality of the learning withinjust-in-time and just-enoughthe content and not how is wasapproaches which deliver relevantdelivered to the user. These earlytraining, on-demand, to thepredictors of e-learning saw theindividual learner in their workplacereplacement of all classroomenvironment. The usefulness ofteaching and that e-learning wastraining is therefore improving,all about the technology. The initialas is the return on investment forofferings excited everybody withcorporate purchasers of training. Thethe level of instructional design andmodern workplace for healthcareinteractivity and this increased theprofessionals has changed andavailability of learning opportunities.e-learning allows the wholeMany organisations quickly jumpedworkforce to participate in learningon the bandwagon and purchasedthat accommodates their workor developed their first generationpatterns and allows them to study atof e-learning technologies, buta time and place that is determinedunfortunately the evaluation of these initial approaches did not by the learner and not by the teaching.support the over-hyped expectations and a downturn in popularityfollowed. The initial hype of e-learning focused on the technology and The problems of traditional teaching can be found in e-learninghas now been replaced by a refocus on the educational pedagogy, too. The largest challenge is to maintain curriculum congruence,producing learning materials that are engaging learners in activities where the intended learning outcomes are matched by the learningthat reward their efforts.activities and addressed by the assessment by choice of method anddepth of questioning. This clearly requires that the method of learningWeb-based learning is here to stay and a number of important and assessment are appropriate for the module outcomes, butlessons have been learned over the last 10 years. The content must more importantly, that they are appropriate for electronic delivery. Abe useful to the learners and technological glitz cannot replace practical skill can be observed from a video, but not easily assessedcontent. The development time and cost of quality resources was using a web cam. Adults learn best when the content is relevant andfrequently underestimated, usually by an order of magnitude. So purpose to everyday issues, when the learner is actively involved ande-learning allows the interaction of users, tutors and content using the objectives are clear and unambiguous, with students demandingtechnology, so e-learning really is about the technology. Everyone more feedback that is timely and constructive. These requirementsgets seduced by the technology and yet successful e-learning is are made both e-learning and traditional teaching and thereforealways about the learning and not the technology. The investment innovative approaches are required to ensure that such requirementsin e-learning should therefore be: 5% in student factors, including are delivered. The difficulty with the online student is that they canstudent training, 10% in the technology, 15% in staff factors, including have a shorter concentration time and often expect a response muchmentoring and staff training, and 70% in content creation. Projects quicker that their face-to-face counterparts. This can increase thethat have technology as the main expenditure often do not deliver burden to the online tutors to respond quickly to student enquiries.on-time nor on budget.Nevertheless, by improving the materials in response to studentqueries, the support requirements can be diminished. It is more aKey points:process of understanding the students and learning from them, which• Don’t believe the hype – look for evidence of what worksin turn allows the delivery team to use their time and resources more• ‘e-‘ is only the method of deliveryeffectively.• focus on excellence in the education, not the technology• invest in your staffThe modern approach to working in teams can, and should, beextended to learning in teams, and multidisciplinary education canbe a powerful tool for deep learning. E-learning provides a meansIn 20 years, education will be different as we move from a justin-caseapproach, like learning algebra at school, to a just-in-time the geographical and temporal boundaries that can impede groupof communication within a learning environment that removessolution, delivering learning immediately after users identify their learning activities. Utilising this approach requires a commitmentneed. There is a constant demand for access to reliable knowledge to high quality materials, simplicity of technology and teaching staffand learning, and users are willing to pay if the service is useful to with appropriate skills. Although e-learning utilises technology as anthem. The technology is well advanced but the problem remains effecter of the teaching, it is important to remember that in e-learningaccess to quality content. In the future, the doubling time for‘e-‘ is only the method of delivery, and that it still requires qualityknowledge will be so short that users will be overwhelmed with both learning content.18 - newsletter fall 2008

Continuing Professional DevelopmentAssessing clinical skills through objective assessment and portfoliosEileen Furlong, Lecturer UCD School of Nursing, Midwifery & Health Systems, Belfield Dubin 4The assessment of clinical skills performance poses a challenge fornurse educators. Two methods of assessing clinical competence arethe Objective Structured Clinical Examination (OSCE) and the use ofPortfolios. This paper aims to highlights key literature on the abovemethods of assessment and discuss some practical examples of howcompetence can assist in the integration of theory with practice.The OSCE emerged as an assessment strategy for medical educationin Scotland during the 1970’s. It is an assessment approach tostudents’ clinical skills that is objective rather than subjective(1). This assessment is used widely in medical education and hasnow emerged in many other disciplines, including nursing. Theclinical competence is divided into various components such ashistory taking, or the interpretation of clinical data (such as nursingdiagnoses) with each component being assessed at a differentstation (2). Students rotate through a number of stations, spending apre-specified equal amount of time at each station (1).There are two principle types of stations: (a) procedure or observerand (b) question or marker stations. Generally the procedure /observer station involves task performance, usually presented in ashort written scenario (1,2). This is followed by a request for therequired action using a pre-determined check-list of criteria, with theperformance being checked by an observer (1,2). The advantageof this checklist should be increased reliability and objectivity (1).The observer stations are particularly suited to clinical skills of aninterpersonal and / or psychomotor nature and also to interveneperformance (2,3). However, many variations exist and some stationsmay be longer and involve multiple choice questions or longer writtenformats (3). The use of a modified OSCE used by oncology nurseshas been evaluated (4). This evaluation was a non-experimental postonlyevaluation of oncology nursing students’ perception of an OSCE.Students were asked to complete the evaluation form indicating theextent to which they agree / disagree, with statements relating totheir degree of preparation for the OSCE exam, their views on theefficacy and relevance of the exam in testing clinical skills and thelevel of anxiety or stress experienced as a result of the OSCE. Thefindings indicated that 90 % of the students (n=185) viewed the OSCEas stressful despite their high level of preparation and affirmativeviews on the relevance of the skills tested. Using the OSCE inconjunction with a number of assessment methods may attempt tomaximise the transfer of knowledge to clinical practice (4).Objective Structured Clinical Examination(OSCE)• Emerged as an assessment strategy for medicaleducation in Scotland during teh 1970’s(Harden & Gleeson 1979)• Adopting by nursing• Approach that is objective rather than subjective• Clinical skills are tested rather than pure theoreticalknowlegde• Clinical skills laboratories and simulation of practicebecame important in nursing faculties/universities inpast decade• A product consistent with adultlearning• Organised collection of writtenevidence• Record of continuingcompetence• Personal and professionaldevelopment• Reflect upon achievements• Assessment of skills andknowledge• Critical analysis of contentsA portfolio used by nurses and midwives is generally understood tobe an organised collection of documents chronicling an individual’scareer. These accumulated documents may be drawn upon whenapplying for jobs or courses in order to demonstrate learning.Portfolio contents can help individual nurses and midwives to identifytheir own strengths and areas requiring development, plan how theycan enhance their knowledge and skills in order to improve clinicalpractice, maximise their opportunities to undertake appropriatecontinuing professional development and develop strategies forachieving their individual career goals (5)The development of a portfolio supports independent and lifelonglearning. It is suggested that portfolio strategy puts students at thecentre of the learning process (6) and encourages nurse to criticallyanalyse care.A major requirement of the nursing profession is to safeguardthe public in providing a valid and reliable means of admitting topractice only those who meet the minimum requirements and whoare deemed competent (7). As nurses in practice, management andeducation we must strive to ensure that competence is achieved.References:1. Harden R.M, Gleeson F.A: Assessment of medical competenceusing an objective structured clinical examination (OSCE) ASMEMedical Education Booklet 8, 3-10, 1979.2. Ross M, Carroll G, Knight J, Chamberlain M, Fothergill-BourbonnaisF, Linton J: Using the OSCE to measure clinical skills performancein nursing, Journal of Advanced Nursing 13 (1): 45-56, 19883. Newble D: Techniques for measuring clinical competence:objective structured clinical examination, Medical Education 38,199-203, 2004.4. Furlong E, Fox P, Lavin M, Collins R: Oncology nursing students’views of a modified OSCE, European Journal of Oncology Nursing 9,351-359, 2005.5. National Council for the Professional Development of Nursing andMidwifery Guidelines for Portfolio Development for Nurses andMidwives, 2006. www.ncnm.ie/publications6. Corcoran J, Nicholson C: Learning portfolios – evidence of learning:an examination of students’ perspectives. British Association ofCritical Care Nurses, Nursing in Critical Care. 9 (5) 230-237 2004.7. Bradshaw A, Merriman C: Nursing competence 10 years on: fit forpractice and purpose yet ? Journal of Clinical Nursing 1263-1269,2008.newsletter fall 2008 -19

TITAN 2008 updateCourses on track!Rudi Briké, TITAN coordinatorSince the beginning of 2008, 7 TITAN courses have beensuccessfully organized in several countries, using the 2008 updatedcourse material.The KOK (Germany) organized 2 courses in February and May 2008,with a total of 31 participants. Both courses received very positivefeedback from the participants and overall, the TITAN course wasjudged to be valuable and useful. One of the participants pointed outthat “ …There should be more nurses doing this training programmeas this is a very good educational project!”. Other participantsparticularly appreciated the good quality of the teachers and theuse of inter active sessions. Further courses are planned in October2008.colleagues and the multi- disciplinary team helping to increaseawareness of prevention, detection and management of thesetoxicities and to improve patient care.The UK also held a TITAN course in Leeds in June 2008, with 13participants, providing a good example of the way to organize andmanage a local meeting for nurses. This course was managedinternally at the Leeds Teaching Hospitals NHS Trust using thehospitals own venue and speakers. . Mrs. Kirsten Midgley (clinicaleducator) chaired and delivered most of the sessions, with theremaining sessions led by the haematology specialist nurse andmembers of the patient education group. “This course was veryuseful and I gained new knowledge, allowing me to transfer this inclinical practice” noted one of theparticipants.TITAN courses are not just takingplace in Europe but have now gone‘International’. The first TITANcourse to take place in the MiddleEast occurred in February 2008 atthe Tawam hospital in Abu Dhabiwith 40 nurses participating. TheTITAN course was very well receivedby the audience, thanks to thefact that no one less than Mr. JanFoubert chaired and presentedthe course. Amgen Middle Eastare busily planning further TITANcourses for nurses in the MiddleEast in 2008.Further TITAN courses are plannedto take place in Austria (AHOP),Belgium (SIOP), Czech Republic,Greece and Italy (AIAO).Lecturing during the IANO course in May 2008The IANO (Ireland) organized their TITAN course in May 2008 with25 participants from both community and hospital based nursescaring for cancer patients. On evaluation, participants found theday very useful and relevant to everyday clinical practice, as one ofthe participants stated: “This course is hugely beneficial to practiceon general non specialized wards.” Another participant pointed out“…all oncology/haematology nurses, no matter how experienced,should do this course. This is a very useful training day, relevant toeveryday practice and increasing the benefit for patients as a result”.Indeed, as part of the programme, participants will now develop adissemination project over the next six months and this may takedifferent forms, such as developing staff/patient education leafletsor workshops. The overall aim is to share information with nursingParticipants who have participatedin a TITAN course shouldundertake a project with the aimof disseminating their enhancedknowledge to their colleaguesor patients experiencinghaematological toxicities, within 6 months of completion of a course.We would like to inform the TITAN course organizers that there willbe once again a TITAN Dissemination project Award organized in2008. The request for nominations has been send to TITAN courseorganizers by e mail and is available on the TITAN section of theEONS website at http://www.cancerworld.org/eonsIf you would be interested in receiving more information about TITANor would like to organize or participate in a course, please contactMr. Rudi Briké at eons.secretariat@skynet.beWith special thanks to Mrs. Jacqueline Baumann, Amgen (Europe)GmbH for her kind assistance.This programme is supported by an unrestricted educational grant fromAmgen (Europe) GmbHnewsletter fall 2008 -21

See you at the jointECCO 15 and 34 TH ESMOMultidisciplinary CongressBERLIN, 20-24 SEPTEMBER 2009www.ecco-org.euEuropean Societyfor Medical Oncology

Introducing Vectibix ® : the first 100% human anti-EGFR monoclonalantibody for mCRC* patients with nonmutated (wild type) KRAS 1The power ofindividualised therapy…NOW IN YOUR HANDS*mCRC: metastatic colorectal cancerReference: 1.Vectibix ® Summary of Product Characteristics 2007.VECTIBIX ® (panitumumab)ABBREVIATED PRESCRIBING INFORMATIONPlease refer to the Summary of Product Characteristicsbefore prescribing Vectibix ® (panitumumab).PHARMACEUTICAL FORM: Vectibix ® 20 mg/ml concentratefor solution for infusion. Each vial contains 100 mgof panitumumab in 5 ml. Excipients: sodium chloride,sodium acetate trihydrate, acetic acid (glacial [for pHadjustment]), water for injection.INDICATION: Monotherapy for the treatment of patientswith EGFR-expressing, metastatic colorectal carcinoma(mCRC) with nonmutated (wild type) KRAS after failureof fluoropyrimidine-, oxaliplatin-, and irinotecancontainingchemotherapy regimens.DOSAGE AND ADMINISTRATION: The recommended doseof Vectibix ® is 6 mg/kg of bodyweight given onceevery two weeks. The recommended infusion time isapproximately 60 minutes. Doses higher than 1000 mgshould be infused over approximately 90 minutes.CONTRAINDICATIONS: Hypersensitivity to the activesubstance or to any of the excipients, interstitialpneumonitis or pulmonary fibrosis.© 2007 Amgen. All rights reserved. PMO-AMG-620-2007SPECIAL WARNINGS AND PRECAUTIONS: Dermatologicreactions: Dermatologic reactions are experiencedwith nearly all patients (approximately 90%) treatedwith Vectibix ® ; the majority are mild to moderate innature. If a patient develops dermatologic reactionsthat are grade 3 (NCI-CTC/CTCAE) or higher orconsidered intolerable, temporarily withhold Vectibix ®until the reactions have improved to grade 2. Onceimproved to grade 2, reinstate administration at50% of the original dose. If reactions do not recur,escalate the dose by 25% increments until therecommended dose is reached. If reactions do notresolve (to grade 2) or if reactions recur or becomeintolerable at 50% of the original dose, the useof Vectibix ® should be permanently discontinued.Pulmonary complications: If pneumonitis or lunginfiltrates are diagnosed, Vectibix ® should bediscontinued and the patient should be treatedappropriately. Hypomagnesaemia: Patients shouldbe periodically monitored for hypomagnesaemia andaccompanying hypocalcaemia every 2 weeks duringVectibix ® treatment, and for 8 weeks after thecompletion of treatment.INTERACTIONS: Concomitant use of Vectibix ® and IFLor bevacizumab and chemotherapy combinations is notrecommended. Increased deaths were observed whenpanitumumab was administered in combination withbevacizumab and chemotherapy combinations. Patientsreceiving Vectibix ® in combination with IFL regimen,leucovorin and irinotecan experienced severe diarrhoea;therefore administration of Vectibix ® in combinationwith IFL should be avoided.PREGNANCY AND LACTATION: There are no adequate datafrom the use of Vectibix ® in pregnant women. In womenof childbearing potential, appropriate contraceptivemeasures must be used during treatment and for6 months following the last dose. It is recommendedthat women do not breast-feed during treatment withVectibix ® and for 3 months after the last dose.UNDESIRABLE EFFECTS: Very common ( 1/10): Rash,erythaema, skin exfoliation, pruritus, dry skin,skin fissures, paronychia, diarrhoea, fatigue,nausea, vomiting, dyspnoea, cough. Common( 1/100 to < 1/10): Infusion reactions (pyrexia, chills),hypomagnesaemia, hypocalcaemia, hypokalaemia,dehydration, headache, conjunctivitis, growth ofeyelashes, increased lacrimation, ocular hyperaemia, dry eye,eye pruritus, stomatitis, mucosal inflammation,onycholysis, hypertrichosis, alopecia, nasal dryness,dry mouth.PHARMACEUTICAL PARTICULARS: Store in a refrigerator(2°C – 8°C). Do not freeze. Store in the original cartonin order to protect from light. Chemical and physicalin-use stability has been demonstrated for 24 hoursat 25°C. Vectibix ® should be diluted in 0.9% sodiumchloride injection using aseptic conditions.LEGAL CLASSIFICATION: Medicinal product subject tomedical prescription.MARKETING AUTHORISATION HOLDER: AmgenEurope B.V., Minervum 7061, NL-4817 ZK Breda, TheNetherlands. Further information is available fromAmgen (Europe) GmbH, Dammstrasse 23, PO Box 1557,Zug, Switzerland, CH-6301. Additional informationmay be obtained from your local Amgen office.Marketing Authorisation Number 100 mg vial:EU/1/07/423/001

Immune Thrombocytopenic PurpuraNew Treatment OptionsBy Dion Smyth, Birmingham City University, Birmingham, UKPlatelet count and symptomsIntroduction24 - newsletter fall 2008Immune (idiopathic) thrombocytopenic purpura (ITP) is a rare • > 50 x 10 9 /L Often asymptomaticautoimmune disorder characterized by low numbers of circulating • 30-50 x 10 9 /L Easy bruisingplatelets. Patients with ITP often have platelet counts of less than • 20 x 10 9 /L Petechiae and purpura50 x 10 9 /L and, although otherwise well, they may feel fatiguedand have an increased tendency for bleeding, easy bruising, orextravasation of blood from capillaries into skin and mucous•

• patients planning to undergo medical or dental procedures likely toprovoke or bring about blood loss, such as the extraction of a tooth• patients with lifestyles associated with an increased risk ofbleeding, such as those participating in hazardous or dangerousactivities such as full-on contact sports.Current treatments for patients with ITPCurrently, four treatment options that focus on reducingplatelet destruction are commonly used: corticosteroids, anti-Dimmunoglobulin, intravenous immunoglobulins (IVIGs), andsplenectomy. Corticosteroids, typically prednisone, are consideredthe first line of therapy and are effective in 50-75% of patients.(8) Unfortunately, the long-term use of corticosteroids can beassociated with various side effects, including hypertension, diabetes,osteoporosis, glaucoma, and in extreme cases, Cushing’s syndromeas well as an increased risk of infection associated with steroidinducedimmunosuppression.Anti-D immunoglobulin is equally effective, but only in 70-75% ofRhesus+ patients in the non-splenectomised setting (4). IVIGsare recommended for patients unresponsive to corticosteroids, orthose with severe bleeding (7). Possible side effects associated withimmunoglobulins include fever, chills, headache, nausea, dyspnea,and chest pain. In rare cases, patients may develop acute kidneyfailure, aseptic meningitis, or haemolytic anaemia following theadministration of immunoglobulins.Splenectomy is an option for patients with severe ITP refractory tocorticosteroids but the trend now is for more conservative medicalmanagement of patients. Patients can have a lifelong increased riskof infection following splenectomy, and 40-50% of splenectomisedpatients later relapse (1).Rituximab is not currently approved for the treatment of ITP but hasdemonstrated efficacy. (9,10). Approximately 45-65% of patients havea response to rituximab (11) but treatment can be complicated dueto unpredictable patterns of response. Some patients have an earlyincrease in platelet counts (after the first or second infusion) whichpeak between weeks 6 and 10; others may have a late responsewhere increases in platelet count are first achieved 6 to 8 weeks aftertreatment initiation and reached a peak count quickly.(12,13)New treatment options for patients with ITPNew therapies developed to address sub-optimal platelet productioninclude growth factors that stimulate platelet production (4). Thefirst recombinant TPO—manufactured by adding the relevant DNAinto the existing genome of bacteria so that proteins are createdthat stimulate the production of platelets—was similar to endogenousTPO produced naturally in the body. The recombinant TPOs provedto be immunogenic and the body’s immune system identified therecombinant TPO as ‘foreign’ leading to the production of autoantibodiesand the destruction of endogenous TPO. The secondrecombinant TPO receptor agonist, romiplostim and the smallmolecule TPO receptor agonist, eltrombopag, currently in late phaseclinical development have no structural similarity to endogenous TPOand do not stimulate an autoimmune response.RomiplostimRomiplostim is a thrombopoeisis-stimulating Fc-peptide fusionprotein (peptibody) which binds to the TPO receptor on the surfaceof platelet-producing megakaryocytes (Figure 3). The binding ofromiplostim activates cell signalling pathways which lead to activationof platelet production (4). Romiplostim is administered as a onceweekly,subcutaneous injection and the dose of romiplostim isindividualised for each patient and their specific platelet level. Theefficacy and safety of romiplostim (1μg/kg weekly) was investigatedin two 24-week, parallel, placebo-controlled, double-blinded, phaseIII trials, one in splenectomised patients (romiplostim N= 42; placeboN = 21) and the other in non splenectomised patients (romiplostimN=41; placebo N= 21) (14). Patients could receive concurrent ITPtherapy with corticosteroids, azathioprine, and danazol. The primaryendpoint of both studies was durable platelet response defined asa weekly platelet count of ≥ 50 x 10 9 /L during at least 6 of the last8 weeks of treatment, in the absence of rescue medication at anytime during the study. Transient response was defined as 4 or moreweekly platelet responses without a durable response from week2-25. Platelet responses that occurred within 8 weeks of rescuetreatment were not included in any measures of platelet outcome.Altogether 83% of the romiplostim-treated patients achieved anoverall platelet response (either durable or transient) comparedwith 7% of patients receiving placebo (p

similar or worse compared with patients with diabetes or arthritis(19). Patients report that the bruising and bleeding resulting from ITPhas a substantial negative effect on their quality of life, and fatigue(possibly due to the anaemia caused by bleeding) hinders theirability to perform their routine daily activities. (20). When presentedwith a patient with ITP, the nurse therefore has to help the patientadapt to the physical and psychosocial demands of the disease. Thechanges to body image associated with corticosteroid treatment,the implications of a potential splenectomy, rehabilitation, roles andresponsibilities, and the risk of sepsis are examples of some of thefears and concerns that nurses should be assessing and addressingwhen informing patients about, and explaining, different treatmentoptions to patients with ITP. Keeping up to date with the developingand future therapeutic options enables the nurse to educate andreassure the patient, thereby potentially alleviating fears of treatmentfailure or that eventual splenectomy is unavoidable.The long-term efficacy and safety of romiplostim are now beingconfirmed in an ongoing, open-label, extension study (15). TheEuropean Medicines Evaluation Agency is currently reviewing theMarketing Authorisation Application for romiplostim. Romiplostimwas recently approved for the treatment of adults with chronic ITP inthe US and Australia.EltrombopagEltrombopag is a small molecule TPO receptor agonist that isadministered orally once-daily. It activates the TPO receptor bybinding to the transmembrane region. Although eltrombopag bindsto the receptor differently than endogenous TPO or romiplostim, thefinal pathways seem to be identical (4). The results from a 6-weektreatment-period, placebo-controlled phase II trial where the primaryend point was a platelet count of ≥50 x 10 9 /L on day 43 of treatmentshowed that 28%, 70%, and 81% of patients receiving, respectively,30 mg, 50 mg or 75 mg of eltrombopag daily achieved this endpoint(versus 11% in the placebo group). (16)When considering the management of the patient, two importantMild to moderate headache was the most commonly reported issues during the treatment of ITP arise: firstly, the need for treatmentadverse event followed by aspartate aminotransferase elevation, concordance and secondly, regular platelet count monitoring. A onceweeklysubcutaneous therapy such as romiplostim may facilitateconstipation, fatigue, and rash. Cataracts have been noted in bothpreclinical and clinical studies of eltrombopag, and elevated alanine concordance; it also combines treatment with frequent platelettransaminase in conjunction with raised bilirubin levels have been count monitoring and reinforces regular contact with medical staffobserved in some patients treated with eltrombopag (17). Phase III which may be reassuring for the patient. This approach facilitatesstudies of eltrombopag are currently ongoing and the published data individually tailored and controlled dosing schedules and minimisesare awaited soon.the risk of thrombosis that might occur if platelet counts increase(e.g. due to irregular drug intake).DiscussionWith the development of the TPO receptor agonists, the treatment In adults, ITP is a chronic disease often associated with a remittingoptions for patients with ITP have been widened. Current treatments – relapsing course. Many patients do not require treatment and thecan have many side effects and the treatment of ITP may result decision to introduce therapeutic interventions will be based uponin increased morbidity from adverse effects and opportunistic the laboratory findings, clinical circumstances, and individual patientinfections, which often surpass the problems actually caused by ITP risk factors. The development of the upcoming TPO receptor agonists(18). The phase III trials investigating romiplostim and the phase II provides patients with a new perspective to living with this chronictrials on eltrombopag show that TPO receptor agonists appear to be medical condition.well-tolerated and effective in patients with ITP (14, 16). As the TPOreceptor agonists are not immunosuppressive agents, the problems Acknowledgementsassociated with immunosuppressive treatment can be avoided and This article was supported by Amgen Europe GmbH, Zug, Switzerland.the overall health of the patient better maintained.Author for Correspondence: 033 Bevan House, Birmingham CityBoth the symptoms of ITP and its treatment affect the quality of life University, Edgbaston , Birmingham, B15 3TN, UK E-mail: dion.of the patient; indeed the impact on quality of life is perceived as smyth@bcu.ac.uk26 - newsletter fall 2008

References1. Cines DB, McMillan R: Management of adult idiopathicthrombocytopenic purpura. Annu Rev Med 56:425-42, 2005.2. Kaye J, Schoonen M, Fryzek J: ITP incidence and mortality inUK general practice research database. Haematologica 92(Suppl.1):280 (Abstract 0751), 2007.3. Bussel J: Treatment of immune thrombocytopenic purpura inadults. Semin Hematol 43 (3 Suppl 5):S3-10; discussion S18-9,2006.4. Stasi R, Evangelista ML, Amadori S: Novel thrombopoietic agents:A review of their use in idiopathic thrombocytopenic purpura.Drugs 68 (7):901-12, 2008.5. Arnold J, Ouwehand WH, Smith GA, Cohen H. A young womanwith petechiae. Lancet 352:618, 1998.6. Azuno Y, Yaga K, Sasayama T, Kimoto K. Thrombocytopeniainduced by Jui,a traditional Chinese herbal medicine [Letter]. Lancet 354:304-5,1999.7. George J, et al.: Idiopathic thrombocytopenic purpura: a practiceguideline developed by explicit methods for the American Societyof Hematology [see comments]. Blood 88 (1):3-40, 1996.8. Cines DB, Blanchette VS. Immune thrombocytopenic purpura. NEngl J Med 346: 995-1008, 20029. Provan D, et al.: Activity and safety profile of low-dose rituximabfor the treatment of autoimmune cytopenias in adults.Haematologica 92 (12):1695-8, 2007.10. Godeau B, et al.: Rituximab efficacy and safety in adultsplenectomy candidates with chronic immune thrombocytopenicpurpura - results of a prospective multicenter phase 2 study.Blood:Epub ahead of print, 2008.11. Arnold DM, Dentali F, Crowther MA, et al. Systematic Review:Efficacy and Safety of Rituximab for Adults with IdiopathicThrombocytopenic Purpura. Ann Intern Med. 2007;146(1):25-33.12. Stasi R, Pagano A, Stipa E, et al. Rituximab chimeric anti-CD20monoclonal a ntibody treatment for adults with chronicidiopathic thrombocytopenic purpura. Blood. 2001;98(4):952-957. Clinical trial.13. Stasi R, Stipa E, Forte V, et al. Variable patterns of responseto rituximab treatment in adults with chronic idiopathicthrombocytopenic purpura. Blood. 2002;99(10):3872-3873.14. Kuter DJ, et al.: Efficacy of romiplostim in patients with chronicimmune thrombocytopenic purpura: a double-blind randomisedcontrolled trial. Lancet 371 (9610):395-403, 2008.15. Newland C, et al.: Evaluating the long-term efficacy ofromiplostim (AMG 531) in patients with chronic immunethrombocytopenic purpura (ITP) during an open-label extensionstudy. Haematologica 93 (Suppl.1):377 (Abstract 0945), 2008.16. Bussel JB, et al.: Eltrombopag for the treatment of chronicidiopathic thrombocytopenic purpura. N Engl J Med 357(22):2237-47, 2007.17. FDA Oncologic Drug Advisory Committee Briefing Document.Promacta (Eltrombopag Tablets) http://www.fda.gov/ohrms/dockets/AC/08/briefing/2008-4366b1-02-GSK.pdf. AccessedJuly 21st 200818. Portielje JEA, et al.: Morbidity and mortality in adults withidiopathic thrombocytopenic purpura. Blood 97 (9):2549-2554,2001.19. McMillan R, et al.: Self-reported health-related quality of life inadults with chronic immune thrombocytopenic purpura. Am JHematol 83 (2):150-4, 2008.20. Mathias SD, et al.: Impact of chronic Immune ThrombocytopenicPurpura (ITP) on health-related quality of life: a conceptual modelstarting with the patient perspective. Health Qual Life OutcomesFeb 8;6:13, 2008Update accreditation• Diploma of Advanced Studies Berner Fachhochschule in Onkologiepflege, Lindenhof Schule, BernSwitzerland, educational programme of study. For more information: www.lindenhof-schule.ch• Chemotherapy course for oncology nurses, Estonian Oncology Nursing society, 14,15,16 April 2008,educational event• ESO “11 Internationales seminar: Onkologische pflege Fortgeschrittene Praxis”., September 2008,educational event. For more information: www.oncoconferences.chnewsletter fall 2008 -27

Personalised Cancer TherapyWhat is KRAS and What Does it Mean for PatientsWith Metastatic Colorectal Cancer?Liesbeth Lemmens, BSc, MSc, Coordinator Clinical Trials, Digestive Oncology Department of Gastroenterology,University Hospitals Leuven, BelgiumIntroductionEGFR as a Therapeutic Target in Colorectal CancerRecent advances in understanding the molecular basis of cancer The EGFR pathway plays a critical role in tumour growth andhave revolutionised medical oncology. Scientists have identified progression (7, 8). The EGFR-mediated signalling activates multiplefunctionally important proteins that are involved in regulating the pathways that result in cell proliferation and survival (Figure 1). Thegrowth, survival, and metastatic properties of tumour cells. These abnormal activation of EGFR is implicated in many types of cancers,proteins have served as targets for the rational design and discovery including 75% to 90% of CRC, and seems to reflect a more aggressiveof novel treatments, referred to as “targeted therapies” (1, 2). pathology and clinical behaviour, such as more tumour angiogenesis,Although many of these novel targeted agents have been shown to proliferation, metastasis, and survival (9-11). As a result, EGFR hasimprove outcomes in clinical trials, it is clear that not all patients been identified as a logical target in cancer treatment, and therapiesbenefit from the therapies. The current research challenge, therefore, have been developed to inhibit this signalling pathway.is to identify indicators that can predict response to treatment (3).The activity of EGFR can be inhibited by either small molecule“Biomarker” is defined as “a characteristic that is objectivelyinhibitors or by monoclonal antibodies. Small molecule inhibitors,measured and evaluated as an indicator of normal biologicalsuch as erlotinib (Tarceva ® ), selectively inhibit the enzyme (tyrosineprocesses, pathogenic processes, or pharmacologic responses to kinase) activity of EGFR inside the cell; thus, they are referred to asa therapeutic intervention (4).” Whereas prognostic biomarkers tyrosine kinase inhibitors or TKIs (12). No TKI has been approvedindicate clinical outcomes independent of treatment, predictive for use in CRC to date. Monoclonal antibodies, such as cetuximabbiomarkers determine the response of a tumour to a specific(Erbitux ® ) and panitumumab (Vectibix ® ), target EGFR outside thetherapy. Consequently, predictive biomarkers are used to identify cell by blocking ligand binding and subsequent activation of EGFRthe treatment option that will result in the best patient outcomes. By signalling (8). In randomised clinical trials, both of these anti-EGFRalso identifying patients who are not likely to benefit from therapy, antibodies have been shown to improve patient outcomes andpredictive biomarkers will prevent exposure to and toxicity from provide alternate treatment options for patients with metastatic CRCineffective treatments while preventing treatment delays with other (mCRC) (13-19).potentially effective regimens and reducing healthcare costs.Despite promising results in clinical trials, not all patients respondThis article explains how personalised medicine may become a reality to cetuximab and panitumumab; in clinical trials, monotherapy withfor patients who have colorectal cancer (CRC) by allowing healthcare these agents yielded response rates of approximately 10% andproviders to select appropriate treatments for patients on the basis disease stabilisation rates of approximately 30% (13-15, 20). Theseof their specific genetic profile. Scientists have recently identified a results led to a search for a biomarker that would help identifydifferential response to antibodies that target the epidermal growth patients who were likely to respond to anti-EGFR therapy.factor receptor (EGFR) based on the presence or absence of amutation of a specific gene called Kirsten RAS or KRAS. KRAS is a Biomarkers for Anti-EGFR Therapypart of the rat sarcoma oncogene virus (ras) family, which encodes EGFR overexpression as a biomarkerthe KRAS protein (5, 6). The biology of EGFR and KRAS, the effect of Preclinical data had suggested that sensitivity to anti-EGFR agentsthe KRAS mutation, and the studies that have led to the identification was linked to levels of expression of EGFR, and patients participatingof KRAS as a clinically relevant biomarker will be discussed.in the initial clinical trials were required to have detectable EGFRprotein expression as determined by immunohistochemistry (IHC)Figure 1: Relationship between EGFR pathway and KRAS in colorectal testing. However, objective responses were seen in patientscancerregardless of EGFR expression status, and the use of EGFR IHC asa predictive marker of response has been questioned despite theproduct labels’ requirement for testing (21-23).Several studies are also evaluating whether the presence of a largenumber of copies of the EGFR gene in the tumour cells (comparedto 2 copies in normal cells) are predictive of response; to date thesestudies have yielded conflicting results (22, 24-27). Thus, levels ofEGFR protein or gene in tumour cells are not considered predictivefor response based on currently available measurement methods.28 - newsletter fall 2008

Skin toxicity as a biomarkerEGFR inhibitors are associated with the development of manyadverse effects, such as hypersensitivity reactions, gastrointestinaldisorders, metabolic disorders (hypomagnesaemia and secondaryhypocalcemia), and dermatologic toxicity (28). Several studieshave shown that adverse skin reactions consistently correlatewith response to cetuximab and panitumumab (29). In fact theoccurrence of a more severe rash upon treatment with cetuximab orpanitumumab predicted a longer progression-free survival (PFS), aswell as overall survival (13-15, 30).Skin rash, however, is not considered a reliable biomarker becauseof the lack of toxicity criteria designed to measure the effect of EGFRinhibitors. Other factors, such as the optimal timing for measuringskin toxicity, also need to be determined (31). In addition, someresponders to anti-EGFR treatments do not display a rash, and somepatients with a severe rash do not respond to treatment (9, 13, 15).Therefore, an emerging issue in the appropriate use of EGFR-targetedtherapy in patients with CRC is to identify an effective method forselecting patients who will most likely benefit from these agents.KRAS: The Quest for Biomarkers of ResponseKRAS is an important protein that plays a crucial role in regulatingcell division. KRAS receives signals from several receptors, includingEGFR, and upon activation regulates other proteins located furtherdown in the complex signalling cascade, which in turn eventuallystimulate cell proliferation and survival (Figure 1). Signalling throughthese cascades is normally tightly regulated. A loss of control of theKRAS pathway can lead to hyperactive signalling in tumour cells andresult in tumour angiogenesis, proliferation, metastasis, and survival(5, 6, 32).Mutations of the KRAS gene are among the most common geneticalterations in solid tumours (5). It was estimated that 35% to 45% ofpatients who have CRC have a mutated form of the KRAS gene, withthe remaining patients having a nonmutated or wild-type gene (20,33, 34). These mutations result in a constitutively activated KRASprotein. In other words, the mutation leaves the KRAS protein alwaysturned “on,” in order that signalling within the cancer cell continueseven in the absence of extracellular stimuli (5, 6, 32). As a result,antitumour effects mediated by anti-EGFR antibodies are bypassedby the mutated KRAS protein (Figure 2). In contrast, in tumours withwild-type KRAS, the signalling pathway is turned on only in responseto ligands, such as epidermal growth factor. This allows for effectiveblockade of the KRAS signalling pathway by antibodies that targetEGFR (5, 6, 32).Early evidence from uncontrolled studies has suggested a correlationbetween KRAS gene mutations and a poorer prognosis (35, 36),leading researchers to ask if KRAS is an appropriate biomarker forpatient selection for anti-EGFR therapy in CRC and other EGFRassociatedcancers.First Step Towards Tailored mCRC TherapyRecently, several studies have indicated that KRAS gene mutationstatus determines whether patients are likely to respond to EGFRtargetedtherapies, such as panitumumab and cetuximab, for mCRC.In 2007, the European Medicines Agency (EMEA) ruled that datawere sufficiently convincing to mandate KRAS testing as part ofthe conditional marketing approval for panitumumab in mCRC. Thisdecision was based on a prespecified biomarker subset analysis ofthe phase 3 trial that showed the superiority of panitumumab overFigure 2: Mechanism by which mutant KRAS overcomes inhibition by ant-EGFR antibodiesnewsletter fall 2008 -29

mutated gene had a median PFS of 5.5 months in the cetuximab armbest supportive care (BSC) in patients with refractory mCRC (20).30 - newsletter fall 2008This analysis was conducted to determine whether the effect ofpanitumumab monotherapy on PFS differed between patients withtumours having a mutant KRAS and those with tumours having awild-type KRAS. When panitumumab was compared to BSC alone, acompared with 8.6 months in the chemotherapy-only arm (P = .02),showing that the addition of cetuximab to FOLFOX had a detrimentaleffect on outcomes in patients who had tumours with KRAS mutationscompared with those who had received FOLFOX alone (34).statistically significant improvement in PFS was observed in patientswhose tumours harboured wild-type KRAS; median PFS was 12.3weeks for panitumumab and 7.3 weeks for BSC (P < .0001). Incontrast, panitumumab treatment conferred no additional benefitcompared with BSC alone (median PFS = 7.4 vs 7.3 weeks) inpatients carrying the mutant KRAS gene (Table 1) (20). Consistentwith these findings, the response rate to panitumumab was 17% inthe wild-type KRAS group, while no patients in the KRAS mutationgroup responded to therapy.The EVEREST trial evaluated the benefit of cetuximab in combinationwith irinotecan after the failure of irinotecan-based treatment. In thisstudy, the PFS estimate in patients with a mutant KRAS was 83 dayscompared to 173 days for patients with the nonmutated KRAS (37).Taken together, these trials provide compelling evidence of thepredictive nature of KRAS in EGFR-targeted therapy. The KRASmutation is a biomarker for nonresponse to panitumumab andto cetuximab, both as monotherapy and in combination withTable 1: Randomised Trials of Anti-EGFR Agents Based on Mutationalchemotherapy. It should be noted that a similar correlation withStatusKRAS mutant status has also been observed in patients treated withsmall-molecule TKIs in non–small cell lung cancer (38-40), as well asMedian PFS (HR) pancreatic cancer (41).Patients, Mutant Wild-typeStudy Treatment No. KRAS KRASImplications for Nursing PracticeIt is imperative that oncology nurses understand the clinicalAmado BSC vs 427 7.3 vs 7.3 vs relevance of these data to treatment decisions for patients with CRC.panitumumab 7.4 wk 12.3 wk Like human epidermal growth factor receptor 2 (HER2) status for(third-line) (HR = 0.99) (HR = 0.45;breast cancer, KRAS status is the first indicator allowing personalisedP < .0001)treatment of CRC. KRAS testing is likely to become a criticalVan Cutsem FOLFIRI vs 540 8.1 vs 8.7 vs(CRYSTAL) FOLFIRI + 7.6 mo 9.9 mocomponent in patient selection for anti-EGFR therapy.All patients being considered for panitumumab or cetuximabtherapy, as well as all patients with newly diagnosed advancedcetuximab(first-line)(HR = 1.07;P = .75)(HR = 0.68;P = .017)Bokemeyer FOLFOX vs 233 8.6 vs 7.2 vs CRC, should have their tumour biopsies tested for EGFR mutation(OPUS) FOLFOX + 5.5 mo 7.7 mo status. Tumour samples should therefore be obtained at the timecetuximab (HR = 1.83; (HR = 0.57; of surgery, regardless of whether the surgery is for diagnostic or(first-line) P = .02) P = .02) therapeutic purposes. Available data indicate that both the primaryTejpar Irinotecan + 148 83 d 173 d and metastatic colorectal tumours exhibit the same KRAS mutation(EVEREST) cetuximabstatus because the mutation of the KRAS gene occurs early in the(irinotecanrefractorypatients may present at the clinic with metastatic disease that wasdevelopment of the disease (42). This is important because manypatients)diagnosed following surgical resection of their primary site or mayBSC, best supportive care; FOLFIRI, irinotecan, 5-fluorouracil,leucovorin ; FOLFOX, 5-fluorouracil, leucovorin, oxaliplatin.; HR,hazard ratio.only have testing results available from the metastatic site. Oncologynurses may play a key role in ensuring that testing for the KRASmutation is requested at the time of surgery and completed prior tothe initiation of treatment.The same result has been found with cetuximab and is the basisfor the recent recommendation by the EMEA to restrict the use ofcetuximab to patients with EGFR-expressing, KRAS wild-type mCRC.The most recent data on this subject come from the retrospectiveanalyses of 3 randomised trials of cetuximab in combination withchemotherapy, the CRYSTAL trial (33), the OPUS trial (34), and theEVEREST trial (37) (see Table 1).Nurses may also play a key role in educating patients about theclinical relevance of the mutant KRAS. It is extremely importantto convey to patients who have a KRAS mutation that currentchemotherapy regimens remain active and effective against theirdisease. The use of the KRAS mutation as a marker for nonresponseallows clinicians to avoid treatment delays with other potentiallyeffective regimens. In addition, clinicians now have a tool to avoidIn the randomised phase 3 CRYSTAL trial, the addition of cetuximabto folinic acid, 5-fluorouracil, and irinotecan (FOLFIRI) in the overallunselected patient population resulted in a small PFS benefit forprescribing costly therapies with known toxicities to those patientswho may derive little or no benefit; and as a result, both the patientand the healthcare system benefit.cetuximab(8.9 vs 8.0 months, P = .0479) (17). As shown in Table1, patients with wild-type KRAS had a median PFS of 9.9 monthswhen treated with chemotherapy plus cetuximab compared with 8.7months when treated with chemotherapy alone (P = .017). Patientswith the mutated gene had a median PFS of 7.6 months in thecetuximab arm compared with 8.1 months in the chemotherapy-onlyarm (P = .75) (33).ConclusionAs new agents are being introduced into clinical practice, moreoptions are available to oncology healthcare professionals and to thepatients they treat. Targeted therapies, and in particular EGFR-directedtherapies, are a key component of treatment for patients with CRC,and the optimal use of these agents is essential. As we enter theera of personalised medicine, the discovery that the mutation in theSimilar results were observed in the OPUS trial, which evaluatedthe benefit of adding cetuximab to folinic acid, 5-fluorouracil, andKRAS gene is a biomarker for nonresponse to the anti-EGFR agentspanitumumab and cetuximab promises to be practice-changing.oxaliplatin (FOLFOX) chemotherapy (see Table 1). In this retrospectiveanalysis, patients with wild-type KRAS had median PFS of 7.7 monthswhen treated with chemotherapy plus cetuximab compared with7.2 months when treated with chemotherapy alone (P = .02), thusconfirming the benefit of cetuximab in this population. Patients with theAcknowledgementsThe author thanks Mary Jensen Camp, Pharm D, BCOP, and SupriyaSrinivasan, PhD, for writing and editorial support. Amgen (Europe)GmbH sponsored an external agency for writing support.

References1. Field K, Lipton L: Metastatic colorectal cancer–past, progress andfuture, World J Gastroenterol 13:3806-3815, 2007.2. Gerber DE: Targeted therapies: a new generation of cancertreatments, Am Fam Physician 77:311-319, 2008.3. Saltz LB et al: Phase II trial of cetuximab in patients with refractorycolorectal cancer that expresses the epidermal growth factorreceptor, J Clin Oncol 22:1201-1208, 2004.4. Biomarkers Definitions Working Group: Biomarkers and surrogateendpoints: preferred definitions and conceptual framework, ClinPharmacol Ther 69:89-95, 2001.5. Bos J: ras Oncogenes in human cancer: a review, Cancer Res49:4682-4689, 1989.6. Boguski MS, McCormick F: Proteins regulating ras and its relatives,Nature 366:643-654, 1993.7. Salomon DS et al: Epidermal growth factor-related peptides andtheir receptors in human malignancies, Crit Rev Oncol Hematol19:183-232, 1995.8. Johnston JB et al: Targeting the EGFR pathway for cancer therapy,Curr Med Chem 13: 3483-3492, 2006.9. Spano JP et al: Impact of EGFR expression on colorectal cancerpatient prognosis and survival, Ann Oncol 16:102-108, 2005.10. Galizia G et al: Prognostic significance of epidermal growth factorreceptor expression in colon cancer patients undergoing curativesurgery, Ann Surg Oncol 13:823-835, 2006.11. Press O et al: Gender-related survival differences associated withEGFR polymorphisms in metastatic colon cancer, Cancer Res68:3037-3042, 2008.12. Roche-Lima CM et al: EGFR targeting of solid tumors, CancerControl 14:295-304, 2007.13. Cunningham D et al: Cetuximab monotherapy and cetuximab plusirinotecan in irinotecan refractory metastatic colorectal cancer, NEngl J Med 351: 337-345, 2004.14. Jonker DJ, et al: Cetuximab for the treatment of colorectal cancer,N Engl J Med 357: 2040-2048, 2007.15. Van Cutsem E et al: Open-label phase III trial of panitumumab plusbest supportive care compared with best supportive care alonein patients with chemotherapy-refractory metastatic colorectalcancer, J Clin Oncol 25:1658-1664, 2007.16. Bokemeyer C et al: Cetuximab plus 5-FU/FA/oxaliplatin(FOLFOX-4) versus FOLFOX-4 in the first-line treatment ofmetastatic colorectal cancer: a large-scale phase II study (OPUS),Eur J Cancer 5(suppl 4):236, 2007. Abstract O3004.17. Van Cutsem E et al: Randomized phase III study of irinotecan and5-FU/FA with or without cetuximab in the first-line treatment ofpatients with metastatic colorectal cancer (mCRC): The CRYSTALtrial, J Clin Oncol 25(18S):164S, 2007. Abstract 4000.18. Hecht JR et al: Interim results from PACCE: irinotecan/bevacizumab +/– panitumumab as first-line treatmentfor metastatic colorectal cancer, http://asco.org, ASCOGastrointestinal Cancers Symposium 2008. Abstract 279.19. Siena S et al: Phase III study (PRIME/20050203) of panitumumabwith FOLFOX compared with FOLFOX alone in patients withpreviously untreated metastatic colorectal cancer: pooled safetydata, J Clin Oncol 26(15S):186s, 2008. Abstract 4034.20. Amado R et al: Wild-type KRAS is required for panitumumabefficacy in patients with metastatic colorectal cancer, J Clin Oncol26:1626-1634, 2008.21. Chung KY et al: Cetuximab shows activity in colorectal cancerpatients with tumors that do not express the epidermal growthfactor receptor by immunohistochemistry, J Clin Oncol 23:1803-1810, 2005.22. Lenz HJ et al: Multicenter phase II and translational study ofcetuximab in metastatic colorectal carcinoma refractory toirinotecan, oxaliplatin, and fluoropyrimidines, J Clin Oncol 24:4914-4921, 2006.23. Hecht J et al: Panitumumab (pmab) efficacy in patients (pts) withmetastatic colorectal cancer (mCRC) with low or undetectablelevels of epidermal growth factor receptor (EGFr): final efficacy andKRAS analyses, http://asco.org, ASCO Gastrointestinal CancersSymposium 2008. Abstract 343.24. Frattini M et al: PTEN loss of expression predicts cetuximabefficacy in metastatic colorectal cancer patients, Br J Cancer97:1139-1145, 2007.25. Cappuzzo F et al: EGFR FISH assay predicts for response tocetuximab in chemotherapy refractory colorectal cancer patients,Ann Oncol 19:717-723, 2007.26. Gravalos C et al: Analysis of potential predictive factors of clinicalbenefit in patients (pts) with metastatic colorectal cancer (mCRC)treated with single-agent cetuximab as first-line treatment, J ClinOncol 25(18S):193S, 2007. Abstract 4120.27. Khambata-Ford S et al: Expression of epiregulin and amphiregulinand K-ras mutation status predict disease control in metastaticcolorectal cancer patients treated with cetuximab, J Clin Oncol25:3230-3237, 2007.28. Lemmens L: How to deal with toxicity of targeted therapies: EGFRinhibitors.EONS Newsletter. Spring 2008:12-15, 2008.29. Agero AL et al: Dermatologic side effects associated with theepidermal growth factor receptor inhibitors, J Am Acad Dermatol55:657-670, 2006.30. Saltz LB: Biomarkers in colorectal cancer: added value or justadded expense?, Expert Rev Mol Diagn 8:231-233, 2008.31. De Roock W et al: KRAS wild-type state predicts survival and isassociated to early radiological response in metastatic colorectalcancer treated with cetuximab, Ann Oncol 19:508-15, 2008.32. Benvenuti S et al: Oncogenic activation of the RAS/RAF signalingpathway impairs the response of metastatic colorectal cancers toanti-epidermal growth factor receptor antibody therapies, CancerRes 67:2643-2648, 2007.33. Van Cutsem E et al: KRAS status and efficacy in the first-linetreatment of patients with metastatic colorectal cancer treatedwith FOLFIRI with or without cetuximab: the CRYSTAL experience, JClin Oncol 26(15S):5s, 2008. Abstract 2.34. Bokemeyer C et al: KRAS status and efficacy in the first-linetreatment of patients with metastatic colorectal cancer treatedwith FOLFIRI with or without cetuximab: the OPUS experience, JClin Oncol 26(15S):178s, 2008. Abstract 4000.35. Andreyev HJ et al: Kirsten ras mutations in patients with colorectalcancer: the multicenter “RASCAL” study, J Natl Cancer Inst 90:675-684, 1998.36. Andreyev HJ et al: Kirsten ras mutations in patients with colorectalcancer: the “RASCAL II” study, Br J Cancer 85:692-696, 2001.37. Tejpar S et al: Relationship of efficacy with KRAS status (wild typeversus mutant) in patients with irinotecan-refractory metastaticcolorectal cancer (mCRC), treated with irinotecan (q2w) andescalating doses of cetuximab (q1w): The EVEREST experience(preliminary data), J Clin Oncol 26(15S):178S, 2008. Abstract4001.38. Pao W et al: KRAS mutations and primary resistance of lungadenocarcinomas to gefitinib or erlotinib, PLoS Medicine 2:e17,2005.39. Tsao M, et al: An analysis of the prognostic and predictiveimportance of K-ras mutation status in the National CancerInstitute of Canada Clinical Trials Group BR.21 study of erlotinibversus placebo in the treatment of non-small cell lung cancer, J ClinOncol 24(18S):365s, 2006. Abstract 7005.40. Massarelli E, et al: KRAS mutation is an important predictor ofresistance to therapy with epidermal growth factor receptortyrosine kinase inhibitors in non-small-cell lung cancer, Clin CancerRes 13:2890-2896, 2007.41. Moore MJ et al: The relationship of K-ras mutations and EGFRgene copy number to outcome in patients treated with erlotinib onNational Cancer Institute of Canada Clinical Trials Group trial studyPA.3, J Clin Oncol 25(18S):202s, 2007. Abstract 4521.42. Loupakis F et al: Evaluation of PTEN expression in colorectal cancermetastases and in primary tumors as predictors of activity ofcetuximab plus irinotecan treatment, J Clin Oncol 26 (15S):178s,2008. Abstract 4003.newsletter fall 2008 -31

MASTERCLASS3 RD ESO-EONSMASTERCLASS INONCOLOGY NURSING21-26 March 2009Sintra, PortugalChair: J. Foubert, BE - N. Kerney, UKThe new-formatted Masterclass in Oncology Nursing programme isdesigned for advanced oncology nurses as a multi-professionaljoint event. Five intensive days of full immersion in modernoncology will create a collective spirit of teaching and learning toimproving clinical skills and patient care.In organ-oriented Clinical sessions focusing on breast cancer,gynecological cancer, prostate cancer, colorectal cancer and lungcancer, an international faculty of experts will deliver clearknowledge of today’s practice and address cutting-edgetherapeutic strategies.Spotlight sessions will facilitate compact update on hematologicalcancers, development in immunotherapy, adolescent patients,cancer and pregnancy and long-term survivorship.Nursing sessions are specific nursing-oriented sessions oncommunication, supportive care, symptom clusters, care of theolder patient, guidelines, side effect management and symptommanagement.Practical training will be offered in the frame of group mentorsessions on advanced clinical practice.ATTENDANCE TO THE MASTERCLASS IS BY APPLICATION ONLY AND SUCCESSFULAPPLICANTS ARE GRANTED FREE REGISTRATION AND ACCOMMODATIONAPPLICATION DEADLINE: 18 DECEMBER 2008For more information contact:European Oncology Nursing Society, EONS SecretariatAtt. Rudi BrikeE. Mounierlaan 831200 Brussels, BelgiumTel: +32 27799923 - Fax: +32 27799937Email: eons.secretariat@skynet.beWebsite: www.cancerworld.org/eons or www.eso.net

Supportive Care in Cancer ConferenceOf the International MASCC/ISOO SymposiumReport by Sara Faithfull, EONS presidentThis conference in the steamy heat of Houston explored the newadvances in symptom management and supportive care. Fatigueassessment and management was very much on the agenda withreviews of cytokine and immunological research that may impact onfatigue as well as studies that identifies the efficacy of exercise. FionaCramp (05-041) presented the results of a systematic review andmeta analysis of fatigue interventions , found that through metaanalysisof 13 studies it was possible to conclude that exercise wasbeneficial for individuals but that more work is required on intensitytraining and timing of exercise interventions. An interesting area ofdebate was the needs of cancer survivors and the impact of nutritionand lifestyle behaviour on future health and well being.Long term side effects of chemotherapy and radiotherapy wereidentified in many tumour groups. Dimitrovska Aneta (10-102) foundin lymphoma patients a high incidence of late effects from cardiacproblems to renal impairment. The high late toxicity identifiedin many of the studies highlights the need for further detectionand research for intervention additional supportive care followingcancer treatment. This was also a theme in paediatric cancer whereevaluation of growth, dental health and gastrointestinal symptomswere affected by the impact of bone marrow transplantationand graft versus host disease. The EONS presentation identifiedthe advance of nursing and symptom science in Europe. Thispaper explored the role of nurses in symptom research and theassessment and non pharmacological management. Nurses atall levels are now expected to assess cancer patient symptoms,address symptom management during all stages of cancer therapyand make judicious decisions about patient follow-up care. From abroader perspective poor symptom management not only impacts,on the patient and carers, but also on economics with greater useof health services.Recent research identifies that symptoms are still a major problemfor cancer patients and that symptoms such as pain, fatigue andbreathlessness are not well managed. There is still much work toaddress unmet needs and to facilitate improvements in patient’squality of life. This conference provided symptom research frombench to bedside with a focus on the evidence base for symptominterventions.Impact Factor is coming…Make your article count!A few tips on how to cite.Please remember to use the full name of the journal - European Journal of OncologyNursing or Eur J Oncol Nursing - to cite articles published in EJON.You must also include the year of publication, the volume number and the pages of thearticle that you wish to cite.Here is an example of how to cite an article:Miller M., Maguire R., Kearney N. (2007). Patterns of fatigue during a courseof chemotherapy: Results from a multi-centre study. European Journal of OncologyNursing, 11 (2), 126-132newsletter fall 2008 -33

Developing European Oncology Nurse EducationSara Faithfull, President EONS, Professor of Cancer Nursing Practice, Faculty of Health and Medical Sciences, Surrey University,Guildford, UKIntroductionneglected. Wood and colleagues (Wood et al. 2000) in focus groupsEducation is clearly an important tool in the development of specialist with non specialist staff found six key areas of training that theynursing within Europe. Awareness of cancer and its treatment felt they required 1) an overview of cancer, 2) treatments and sideand the impact it has on individuals and families helps in reducing effects, 3) communication skills, 4) physical and practical issues, 5)negative perceptions and fatalistic attitudes. Education not only care organisations, referral routes and staff roles and 6) finally deathimproves care, but can enhance patient outcomes. However care and dying issues. Similar areas of need were found in communityis becoming more complex with the ever changing and increasing sector staff in Kelly’s (2006) training needs analysis study. Thesecomplexity of cancer treatment delivery, which is demanding wider studies indicate a workforce who would benefit from continuingskills and critical thinking within health care professionals. Individuals professional education in cancer care. This is an area that needswith cancer are being cared for in community and ambulatory to be developed and it is hard to envisage how future home basedsettings, as well as in the traditional cancer centres, and this has chemotherapy and rehabilitation will progress without consideringcreated the need for widening cancer knowledge to nurses working such community staff training needs.in generalist specialities such as community and public health. EUdirectives provided political pressure to ensure the effectivenessand efficacy of cancer care raising the profile by identifying the needto improve knowledge of oncology within the EU member states.The commission identified the vital role of the different professionsin the provision of cancer therapy; rehabilitation and terminal care(EU 1997). The Europe against Cancer programme encouragednew initiatives such as training programmes. This legitimatised theneed to improve the knowledge and skills of health professionals incancer as well as in cancer prevention, counselling and the supportof training networks. Eleven years on and it is time to reflect onhow education has developed and where we should be going for thefuture in modernising cancer nursing education. This paper exploresthe challenges ahead in how we develop our future cancer nursingworkforce.Change in cancer provision; is it challenging educators?Over the last 10 years cancer care has been changing. Developmentsinclude reforms of health care systems, changes in treatment andthe development of consumer focused provision. From all the Is it possible to identify the impact for patients and nurses ofrecent projections and figures we know that with the increasing cancer education?ageing population that cancer burden within Europe will rise over Evidence is limited as to whether current educational provisionthe next 10 years. We also know that those individuals who have is fit for purpose in meeting the new technological and acutecancer are more likely to be surviving their diagnosis and requiring patient agenda for providing 21st century cancer care. There areprolonged monitoring and greater rehabilitation needs (Berino 2007). few evaluation studies of continuing professional cancer nursingResponding to these scientific and technological innovations is education. Ferguson (1994) in a review of the literature to examinedifficult as often health services reform follows major change with the purpose and benefits of continuing professional education forlittle planning or educational provision. The reality is that throughput cancer nurses reported that studies to measure practice benefitsof patients is high within cancer centres, bed stays are short and were inconclusive. Subsequent cancer education studies indicatehospital treatment is increasingly acute. The increased use of similar findings in relation to practice change (Langton 1999, Wyattambulatory care and oral medication has shifted care from hospitals 2007a). Although not oncology based, studies of bachelor nurseto the home where the provision of specialist nursing is often limited programmes have found, that graduate nurses perform significantly(Faithfull 2006). Providing such supportive care requires translation better at decision making than their non academic colleagues (Girotacross disciplines and care settings with multi-agency approaches 2000). Evidence for the effectiveness of education and trainingto care (Boal et al. 2000, Webb 1991). These changes coupled for communication skills in oncology has been well establishedwith ever increasing demands in health care require a constantly (Wilkinson et al. 2002) however the sustainability of their use indeveloping and flexible nursing workforce. Much of the specialist practice has still to be ascertained. Practice outcomes are difficultcancer provision is acute cancer centre based, however clearly much in oncology as such studies require comparators and are scarce,of the care is now being provided in community and general health much of the evidence is based on limited UK or USA educationalcare settings. The need to up skill community and public health provision. It is imperative that in the era of evidence based care,practitioners is a priority for future political agendas but it is unclear educators demonstrate their contribution to clinical outcomes. Oneas to what skills they require and how to identify those who have of the problems for such research is that it is easier to evaluate thetraining needs? Those nurses working in the community are often processes of education than the outcomes (Jordan 2000).34 - newsletter fall 2008

It is not surprising that process evaluations of nurses practiceperceptions has been the most common way of evaluating theimpact of continuing professional education. Studies of the nursesthemselves indicate that continuing professional education improvesconfidence, communication skills and decreases anxiety (Copp etal. 2007) it also has a perceived impact on practice (Wyatt (2007b,Pelletier et al 2004, Steginga et al 2005). A study of a UK healthprovider found that nurses’ perceptions of training needs are oftendifferent from that of health managers and that curriculum contentwas often generic and not adapted to reflect cultural characteristicsof the local health population and health economy (Kelly et al 2006).The wide variation in continuing educational provision has beenseen in specific courses such as in chemotherapy administrationand training with some nurses receiving minimal education in theunderpinnings of knowledge required for safe chemotherapy practice(Verity R et al 2008).Clearly saying is not the same as doing?Developing both processand outcome evaluationof continuing professionaleducation is requiredwithin Europe with aneed to look at specificcancer nursing skill setsand comparator groups.Proving the “value added”nature of educationis essential if we areto develop specialistcancer nursing. As wellas research in this areawe need to identify thecosts and consequencesof up skilling theworkforce for healthservice managers andpolicy makers. There is aneed to recognise suchspecialist skills as partof employment providingfinancial incentives and job satisfaction. In many countries there isno recognition of specialist nursing roles and there is little financialincentive or support for the development of specialist cancer skills(Foubert & Faithfull 2006). Barriers to education and training are notonly financial they can be time related and reflect accessibility (Wyatt2007a). However effective continuing professional development hasbeen linked with enhanced morale, increased motivation and staffretention so also provides benefits for managers (Smith & Topping2001). Unpacking the complexity of these outcomes is essential ifspecialist cancer nursing is to be valued.ConclusionRecognising that the developments within education have been quitedramatic in the last few years more is being required of educators.Furthermore increasing financial constraints in education hasmeant that nurses are finding it difficult to get release and fundfurther continuing professional development within many EU clinicalsettings. There is also an increasing need for short more work-basedprogrammes to enhance accessibility. The development of the EONSpost basic cancer nursing curriculum has made an impact on learningresources providing a gold standard for educational provision withinEurope but requires evaluation of the outcomes that result as part ofthis education. Future development of new specialist curricula andadvancing levels of practice through consensus and expert panelsidentify these curricular as recognised professional education forspecialist cancer nurses. We need more evidence as to the valueof specialist education in outcomes that policy makers and healtheconomists understand. Providing a trained and skilled workforcewill have benefits not only for nurses themselves but in patientcare. Those in nurse education face many challenges not only in theprocesses of how cancer education is provided and to whom, butalso in redefining the skills needed by the cancer workforce to clearlyimpact on the practice outcomes.References:Berino F et al. (2007) Survival for 8 major cancers: results of theEurocare4 study. Lancet Oncology 8(9) 773-783Boal E, Hodgson D, Banks-Howe J, & Husband G (2000) A culturalchange in cancer education and training European Journal of OncologyNursing 9,30-35Copp G, Caldwell K, Atwal A, Brett-Richards M, Coleman K (2007)Preparation for cancer care: perceptions of newly qualified healthcare professionals European Journal of Oncology Nursing 11 159-167European Commission (1997) Public Health in Europe employmentand social affairs, EC LuxembourgFaithfull S (2006) E. Milly L. Haagedoorn Lecture EACE 2006.Developing oncology nurse education and training across Europe. JCancer Educ. Winter; 21(4):212-5.Foubert J, Faithfull S (2006) Education in Europe: are cancer nursesready for the future? J BUON. 2006 Jul-Sep;11(3):281-4.Ferguson A (1994) Evaluating the purpose and benefits of continuingeducation in nursing and the implications for the provision ofcontinuing education for cancer nurses Journal of Advanced Nursing19, 640-646Girot EA (2000) Graduate nurses: critical thinkers or better decisionmakers? Journal of Advanced Nursing 31(2) 288-297Jordan S (2000) Educational input and patient outcomes: exploringthe gap Journal of Advanced Nursing 31 (2) 461-471Kelly D, Gould D, White I, Burridge EJ (2006) Modernising cancer andpalliative care education in the UK: insights from one cancer networkEuropean Journal of Oncology Nursing 10 187-197Langton H, Blunden G, Hek G (1999) Cancer nursing education:literature review and documentary analysis: English National Board forNursing, Midwifery and Health Visiting, LondonPelletier D, Donohue J, Duffield C (2004) Australian nurses’perceptions of the impact of their postgraduate studies on theirpatient care activities. Nurse Education Today 23 434-442Smith J & Topping A (2001) Unpacking the ‘value added’ impactof continuing professional education: a multi-method case studyapproach Nurse Education Today 21 341-349Steginga SK, Dunn J, Dewar AM, McCarthy A, Yates P, Beadle G.(2005) Impact of an intensive nursing education course on nurses’knowledge, confidence, attitudes, and perceived skills in the care ofpatients with cancer. Oncol Nurs Forum. Mar 5;32(2):375-81.Webb P, (1991) Educational initiatives for cancer nursing in Europe. JCancer Educ. 6(1):9-14.Wilkinson S, Gambles M, Roberts A (2002) The essence of cancercare: the impact of training on nurses’ ability to communicateeffectively Journal of Advanced Nursing 40(6) 731-738Wood C & Ward J (2000) A general overview of the cancer educationneeds of non-specialist staff. European journal of Cancer Care 9191-196Wyatt DE. (2007a) The impact of oncology education on practice--aliterature review.Eur J Oncol Nurs. 2007 Jul; 11(3):255-61.Wyatt D (2007b) How do participants of a post registration oncologynursing course perceive that the course influences their practice? adescriptive study European Journal of Oncology Nursing 11, 168-178Verity R, Wiseman T, Ream E, Teasdale E, Richardson A (2008)Exploring the work of nurses who administer chemotherapy EuropeanJournal of Oncology Nursing doi:10.1016/j.ejon.2008.02.001newsletter fall 2008 -35

gave some useful hints as to the educational preparation for some ofthe less known areas. All participants received a packet of forgetme-notseeds which were labelled “encouraging growth”.Early Toxicities/ Delayed education: Providing Safety and Qualityin the Management of Oral Therapies was a session devoted to theproblems with the increasing number of oral cancer drugs in theU.S. and in Europe. Deficits in nurses’ knowledge of pharmacologyand poor communication patterns both with patients and physiciansappear to be ubiquitous. Using keypads it was shown that the worksettings of 63% of the attendees do not have specific tools to teachpatients about oral agents. Roberta Strohl presented some strategiesto rectify the problems.Also on Saturday, another excellent lecture about adherence tooral tumor therapies was presented. Of particular interest was thepresentation from Karin Schulte, (Dana Farber Cancer Institute). Sheshowed the results of her study on the assessment of current nursingpractice associated with oral chemotherapy adherence. Keeping themessage short, one could ask: If we were involved earlier, would theadherence be better? This is a problem that seems to be universal.On similar lines, several lectures focused on molecular targets,whether in applied research (bench) to clinical application (bedside).The profiling of molecular characteristics has allowed singlegenes, growth factor receptors, and other molecular targets to berecognised not only for treatment purposes but for prevention and forearly detection as well. With the targeted therapies, new side effectshave taken on an important part in daily nursing activities. As inthe EONS educational program, TARGET, one lecture also dealt withdermatological toxicities and the nurse’s role in providing care duringtreatment.Carol Estwing Ferrans, PhD, RN, FAAN, Professor and Associate Deanfor Research from the University of Illinois at Chicago, presentedthe Distinguished Research Special Session lecture, Research -Exposing the Deadly Difference. Ms. Ferrans demonstrated withher research findings that through nursing research change canbe made in healthcare policies, legislation and increased fundingto alleviate some health care disparities. Dr. Ferrans studied theprevalence of racial disparities in women with breast cancer andthe higher mortality incidence due to these disparities. The resultswere incredible and dramatic and left one wondering how thesedisparities could even arise. It truly left one with an “Oh, no – notpossible” feeling when looking at the facts and figures. One outcomeof the study was positive: An inaugural meeting of the Consortiumof Metropolitan Chicago Institutions dedicated themselves towork together to improve quality of care. We might have a look atdisparities in health care on the European level – the sooner thebetter.Saturday morning started with the traditional Mara MorgensenFlaherty Memorial Lectureship. Terry A. Badger, PhD, RN, FAANpresented an excellent lecture entitled Depression Assessment andPsychosocial Interventions for Cancer Survivors and Partners. Thelecture started with the re-definition of the social network: changein the traditional household and who is important. Her take-homemessage was: If you are important to the person you are a partnerwhether or not related by blood or marriage.Briefly, the content of her lecture dealt with the facts that depressionis an important issue in cancer survivorship and it significantlyinfluences cancer recovery, quality of life and possibly, long-termsurvival. Further, partners of cancer survivors often suffer the sameor higher levels of emotional distress as the patient. She describedseveral barriers which hinder the assessment process. Finally, shestated that all nurses can provide assessment, patient education andinformation, referrals and therapeutic social support.One of the last sessions on Sunday morning, was “Clinical HotTopics”. This presentation featured several of cancer treatmentmodalities, the place of pharmacovigilance and pharmacogenomicsin cancer treatment, special nursing considerations for emergingside effects of these drugs, and how cancer genetics may influencetreatment decisions in the future.Other HighlightsMeeting with the executive board of ONS as well as various ONSproject leaders was a highlight of the conference for me. Topicsrelating to possible EONS/ONS collaboration were discussed andmapped out. Further talks with Paula Rieger Trahan (ONS CEO),Len Mafrica (International Affairs), Brenda Nevidjon (President) andGeorgia Decker (Past president) will explore the possibilities of thecollaboration of EONS with ONS. We agreed that we could imaginejoining forces on developing guidelines and leadership programsadapting the content accordingly to European circumstances.There was time in the evening to see a bit of Philadelphia, visit theparks, enjoy a baseball game with the “Phillies” (they won) and getthe feel of life outside of oncology nursing.To say the least, after five days of conference one left with a wealthof information and with a feeling of confirmation that one is doingthe right thing. I also had the feeling that we have a great task aheadof us in light of the changing health care systems around Europeand the world and it will be a challenge to provide competent, safe,and equal cancer nursing care for all. I came away realizing thatEuropean nursing does not differ greatly from that in the U.S. butbecause of the structure of Europe we definitely have greater gaps inthe standardization of cancer care.newsletter fall 2008 -37

“Sol Omnibus Lucet” -The Sun Shines on Everyone-The Faculty of Health Sciences of Semmelweis University Hungary,BudapestProf. Judit Mészáros Ph.D. Dean, Csaba Avramucz RN, MSN, assistant lecturer Semmeweis University Faculty of Health SciencesOur motto “The sun shines on everyone” is meant to characterizethe foundation of both our personal and professional approach to thework we do. This ancient phrase represents the ethical paradigm thatthere are no fundamental differences between people regarding trulyimportant things that are common to all of humanity.Hungary, as a member of the European Union, belongs to the unifiedEuropean Higher Education Area, which in principal follows the Britishand American multi- cycle (bachelor, master and doctorate) trainingsystem. The qualifications are comparable and recognized acrossEurope. In this system it is much easier for students, lectures andresearchers to travel and build international relations, moreover, ascitizens of the European Union they can continue their studies andplan their future as employees or entrepreneurs in each memberstate. These opportunities open up a wider field also for non-European citizens studying in Hungary, since the possibilities ofinternal mobility inside the unified Europe are based on the trainingchannels and close relationships between countries, in the labourmarket and among institutions.Semmelweis University is Hungary’s largest higher educationinstitution training physicians and health care professionals. Presentlythere are more than 8000 students studying at this over 200- yearold university. The Faculty of Health Sciences of SemmelweisUniversity provides training at an international level in the field ofhealth sciences and awards internationally competitive diplomas.There is an ever increasing choice in training health professionalswith about 200 lectures and part- time teachers of distinctionworking within the Faculty.The Faculty offers study rooms, lecture halls, computer rooms,specialist laboratories, a public library, all equipped with state-of theart technology, as well as a great variety of active student life and amotivating environment to prospective students. There are also jobopportunities for students within the University during term- time andthe summer vacation. The main advantage attracting internationalstudents is that while the level of training is outstanding, tuitionfees and the cost of living are considerably lower than at any otheruniversity in Central and Western Europe.The range of job opportunities covers a large area in Hungary andnaturally in all countries in the European Union. Besides the generalopportunities of employment- primary care, out- patient clinicnetwork, in- patient care- graduates can get jobs in range of areasthat have emerged recently in the field of health care (e.g. visitor ofsurgeries, pharmacies and hospitals, transplantation coordinator,and nurse and organizer in various health care servicing enterpriseswithin the private sector). The physician, pharmacist, dentist,nurse and midwife diplomas issued by Semmelweis University areuniversally accepted in the member states of the European Union.There is a shortage of trained nurses in Europe and the UnitedStates of America, so it is fairly easy for our graduates to obtain workpermission there.The structure of the BSc programmes in the multi- cycletraining system in terms of specializationNursing and patient care programme• Nurse specialist programme (full time and correspondence course)• Dietician specialist programme (full time and evening course)• Physiotherapist specialist programme (full time and eveningcourse)• Paramedic specialist programme (evening course)• Midwife specialist programme (full time and correspondencecourse)Health care and prevention programme• General public health inspector specialist programme (full time andcorrespondence course)• Health visitor specialist programme (full time course)Medical laboratory and diagnostic imaging programme• Diagnostic imaging analyst specialist programme (evening course)• Optometrist specialist programme evening course)The structure of the MSc programmes in the multi- cycletraining system in terms of specialization• Nursing and patient care master’s programme• General public health master’s programme• General public health officer specialist programme• Health care manager master’s programmeOur postgraduate training programmes• Substance abuse counselor, health care manager, school nurse,clinical engineer, cardiology technician, wellness manager, acutecare nurse.The Transatlantic Nursing Curriculum Project (TCN)A unique international project has been started to educate nursesat Semmelweis University, Faculty of Health Sciences. Against theframework of being the largest transatlantic curriculum projectbetween the European Union and the United States, for the first timea dual-degree can be given with Hungarian contribution in the fieldof health science. The common consortium between SemmelweisUniversity, Faculty of Health Sciences (Hungary), Nazareth College ofRochester (USA) and Laura University of Applied Sciences (Finland)offers a possibility for nurses to accomplish some courses at theNazareth College of Rochester in the United States with scholarshipsupport from the European Union. The university offers the AmericanBSc nurse degree and the purchase of work registration. Thecooperation agreement was signed on 23 June 2008 at the Faculty ofHealth Science, Budapest.newsletter fall 2008 -39

In this unique program the American, Finnish and Hungarianinstitutes share a common concern for developing a new healthtraining programme which can exceed the BSc system considering itstransatlantic objectives.The support of the Atlantis Program, which is the base of thecooperation, has already been won by 107 transatlantic consortiums.However, it is the first cooperation regarding nursing education whichis aimed at the development and purchase of a training graduateaccepted on both continents (Europe and North-America).All students with such scholarship can receive a degree at bothSemmelweis University and Nazareth College through the mutualadmission of the studies between their institutes. In addition, theycan get the possibility to make a NCLEX test (American nursingregistration test). In the course of the students’ foreign studies, theycould acquire vocational-, cultural- and lingual - communicationalknowledge, experiences and competences which could influencetheir whole vocational career and they can get new job opportunitiesboth in Europe and in America. Through their foreign studies they willhave the possibility to do their thesis and to continue their work usingthe opportunities of the receiving institution.This September, 16 students are going to start the training, 8American students and 8 European (4 Hungarian and 4 Finnish).Ones students can participate in the programme after an applicationprocess and they will study in Finland, America and Hungary in thefollowing four years. The education is free and the students obtain ascholarship.Lectures and seminars are held in English, which may mean greatadvantage in case of finding a job either in Hungary or abroad.International relationsThe Faculty takes pride in its extensive international relations in Europe,Asia and America. In Europe under the scheme of the ERASMUSExchange Programme every year 15-20 students and lectures have theopportunity to enhance their professional skills and knowledge abroad.Students spend 3 month in their fourth year at the Finnish, Swedish,Norwegian, Dutch, Belgian, Greek, Spanish and Turkish partnerinstitutes, where they participate in professional training. In addition,there are shorter, 1-3 weeks long further training course available forthem within the framework of the ERASMUS programme and throughthe coordination of the COHEHRE organisation for European highereducation in health. The international scholarship can be obtainedvia application. Every year there are scholarship students who spenda whole month in the United States and who are also selected withthe help of application. The Nazareth College of Rochester, New YorkState annually organises a four – week long intensive English language,professional and recreational programme for our students in July. Allthe registered students of our faculty can submit their applicationfor this training, in which almost 100 students and lectures haveparticipated in the last three years.The Faculty of Health Sciences has partnerships with severalrenowned universities also from the Asian region ( Anhui Universityof TCM, Beijing Medical University, Shanghai Jiao Tong University,Shenyang Chinese Medical University), which provides furtheropportunities for students and lecturer exchange.Should you need any information about our educational programmes(including the training of oncology nursing); please don’t hesitateto contact us. Ideas or suggestions for eventual future internationalcollaboration are most welcome too. To contact us, please use:meszarosj@se-etk.hu OR csabaavramucz@yahoo.com. For furtherinformation log on to: http://www.seetk.hu OR www.tcn-atlantis.orgA Summary of the Bologna ProcessIn summer 1999 the European ministers of education met in Bologna Directive on Mutual Recognition of Professional Qualifications ofwhere they agreed to establish a “European Higher Education Area”. Nurses. The objectives of the Bologna Process are:This involved the introduction of the Bachelor’s and Master’s degrees • Adoption of a system of easily accessible and comparable degrees(a 3-tier educational system) by 2010. The degrees would be valid (Bachelor’s Master’s and PhD degrees)throughout Europe and meet international norms. The Bologna • Establishment of a European credit transfer systemProcess aims to strengthen the competitiveness of European colleges • Promotion of mobilityand universities and support the mobility between educational • Promotion of European co-operation in quality assuranceinstitutions and courses of study.• Promotion of the European dimension in higher education• Life long learningAs a result of the Bologna process, European colleges and• Greater involvement of studentsuniversities are not only optimizing their former academic structures, • Attractiveness and competitiveness of the European Higherbut also the content of their academic programmes. The reform of Education Areahigher education has resulted in new opportunities to address age-oldproblems and actively pursue academic policies. Uniform admission In follow up to the original meeting, working groups on mobility,criteria, practical application, a clear orientation of competence employability, qualifications, lifelong learning, social dimensions,and streamlined degree programmes can reduce the average and the position on the European Higher Education Area in a globallength of study and increase the number of graduates. Innovative context have been recently established. Of particular interest isand interdisciplinary, courses of study have given universities a the agreement that the 46 Bologna signatory countries will developcompetitive edge both nationally and internationally.national qualification frameworks, to be referenced against theBologna 3-tier structure, by 2010.The Bologna Process and the European Qualification Framework More information on the Bologna Process is easily available in manyare without a doubt having an impact on Directive 36 which is the languages on the internet.40 - newsletter fall 2008

Addressing the Training Needs of the Cancer WorkforceInsights from one Cancer Network in LondonDr. Daniel Kelly, Reader in Cancer & Palliative Care, School of Health & Social Science, Middlesex University, LondonEducation and training are considered central to the delivery of theUK Government’s modernisation agenda for the National HealthService with more than £3 billion now being invested in suchactivities each year. Strategic Health Authorities in England areexpected to ensure that education (including cancer education) isrelevant to the needs of local health economies. For example theStrategic Health Authority for the capital – known as NHS London- manages the performance of 31 primary care trusts, 35 acutetrusts, 9 mental health trusts and the London Ambulance Service.Continuing Professional Development (CPD) and lifelonglearning strategies are intended to be closely aligned to servicemodernisation and the needs of patients themselves. In a rapidlychanging health service, a key requirement is that value for moneyand research evidence is taken into account when commissioningeducation for the workforce. The National Cancer Plan (2000) alsoemphasised the need for ‘Investment to tackle key gaps in thecancer workforce and make better use of existing staff’ (p.11).This presentation concerns a study carried out in an inner-London Cancer Network in 2004-05. The aim was to explore whatopportunities existed for professionals involved in the delivery ifcancer care in specialist and general settings- as well as thoseinvolved in delivering care in the home.MethodsUsing a range of survey and interview methods, 94 professionalswere asked about their training needs in relation to theirprofessional role, current education and training opportunities andfuture education priorities. An analysis of cancer-related contentfrom the nursing and medical school curricula of three localuniversities was also carried out. Findings from the National CancerPatient Survey for the same Cancer network were used to provideinsight into needs of patients. Ethical approval was obtained fromthe local Research Ethics Committee.Key findingsFindings from the study suggest a dominance of uni-professional,specialist cancer nursing focus with gaps for key members of theworkforce (e.g. health care assistants, community nurses, alliedhealth professionals and senior nurses). There was a lack of interprofessionaleducation within the university sector although thiswas more common in the practice sector when education eventswere provided. The curricula of programmes did not reflect theethnic or social profile of the local health economy and much of theCPD available had been continually provided for a number of yearswith little evidence of innovation.ConclusionsThe training needs of the workforce in this Cancer Network werenot reflected fully within available CPD courses and the needs ofsome members were being poorly addressed. In order to ensurethat education meets the changing needs of the cancer workforcethere is a need for more responsive commissioning as well as morecreative provision by the university sector in the UK.ReferencesDepartment of Health (2000) National Cancer Plan. Her Majesty’sStationery Office, London.Kelly D, Gould D, White I, Berridge EJ (2006). Modernising cancerand palliative care education: insights from one cancer network.European Journal of Oncology Nursing, 10: 187-197.Gould D, Kelly D, White I, Glen S (2004). The impact of thecommissioning process on the delivery of continuing professionaldevelopment for cancer palliative care. Nurse Education Today. 24:443-443.newsletter fall 2008 -41

23-25 April 2009SARAJEVO, BOSNIAAND HERZEGOVINAChairCo-ChairsHost ChairT. Cufer, (SI)H. Basic, (BA) (ESO)G. Maistruk, (UA) (EUROPA DONNA)J. Foubert, (BE) (EONS)S. Beslija, (BA) (Sarajevo)ScopeFurther to the successes of the first Interconference Breast Cancer Meeting2007, IBCM returns to bring the very latest in breast cancer research,treatment, care to the Balkan area, Central and Eastern Europe.Within a truly multidisciplinary and multi professional setting, participantscan expect a comprehensive review of cutting edge discovery from breastcancer biology and the clinic, the latest trends and developments innursing care as well as updates on topical issues from the patient advocacyperspective.To discover the many programme highlights of interest to the Europeanoncology nursing community including the joint Europa Donna and EONSsession on What do we need to know about counseling and prevention?and the Educational Session on Nursing intervention in breast cancer andso much more, EONS invites you to download your copy of the AdvanceProgramme and register today at: www.ecco-org.eu (select ‘congressesand conferences’ > ‘IBCM-2’).Dates to BookmarkAbstract submission open: 01 November 2008Early rate registration deadline: 12 January 2009SecretariatFor further information and general enquiries please contact the IBCM Secretariatdirectly:ECCO – the European CanCer OrganisationAvenue E. Mounier 83B-1200 BrusselsBelgiumTel: +32 2 7750201Fax: +32 2 7750245Email: IBCM2009@ecco-org.euVenueParlamentarna Skupstina Bosne I Hercegovine(National Assembly Sarajevo)Trg BiH,171000 SarajevoBosnia & Herzegovina